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ABSTRACT: Autopsy studies remain an essential tool for understanding the patterns of fungal disease not detected ante mortem with current diagnostic approaches. We collected data concerning the microbiological trends, patient clinical characteristics and sites of involvement for invasive fungal infections (IFIs) identified at autopsy in a single large cancer treatment centre over a 20-year period (1989-2008). The autopsy rate and IFI prevalence both declined significantly during the study period. The prevalence of Aspergillus spp. decreased significantly from the first 15 years of the study (from 0.12 to 0.14 cases per 100 autopsies to 0.07 in 2004-2008; P = 0.04), with only Mucorales accounting for a greater proportion of IFIs over the duration of the study period (0.06 to 0.2 cases per 100 autopsies, P = 0.04). After 2003, moulds accounted for the majority of infections identified at autopsy in the spleen, kidney, heart and gastrointestinal tract. Despite a trend of decreasing prevalence from 1989 to 2004, invasive candidiasis increased in prevalence during later periods 2004-2008 (0.02-0.05 per 100 autopsies) with decreasing kidney, heart and spleen involvement. Despite a declining autopsy rate, these data suggest a decreasing prevalence overall of IFIs with changing patterns of dissemination in patients with haematological malignancies.
Mycoses 04/2013; · 2.25 Impact Factor
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ABSTRACT: A continuous dosing schedule of aerosolized ribavirin has been used for respiratory syncytial virus (RSV) upper respiratory tract infection and lower respiratory tract infection (LRTI) but is associated with high cost and inconvenient administration. We conducted an adaptive randomized trial to evaluate the effectiveness of an intermittent dosing schedule of ribavirin versus that of a continuous dosing schedule of ribavirin in preventing RSV LRTIs in 50 hematopoietic stem cell transplant recipients or patients with hematologic malignancies. LRTI occurred in 3 patients (9%) receiving the intermittent schedule and in 4 (22%) receiving the continuous schedule, with a 0.889 posterior probability. Because the intermittent schedule is easy to administer and has a higher efficacy than the continuous schedule, we recommend the intermittent schedule for patients who are at risk for RSV LRTI. Clinical Trials Registration. NCT00500578.
The Journal of Infectious Diseases 08/2012; 206(9):1367-71. · 6.41 Impact Factor
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Critical care medicine 04/2011; 39(4):875-6. · 6.37 Impact Factor
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ABSTRACT: Neutrophils provide protection against a wide variety of common and opportunistic bacterial and fungal pathogens. Consequently,
the frequency and severity of infections caused by these organisms is increased in patients with neutropenia. At most cancer
treatment centers, Gram-positive organisms are isolated more frequently from neutropenic patients with documented bacterial
infections than Gram-negative bacilli, although institutional and regional differences occur as do periodic shifts in the
spectrum of bacterial infections. Candida spp. and Aspergillus spp. remain the most common fungal pathogens in this setting, although a number of opportunistic fungal pathogens have emerged.
The prompt administration of empiric, broad-spectrum, parenteral antibiotics in the hospital when a neutropenic patient becomes
febrile is the standard of care. Over the past decade, it has become possible to reliably identify “low-risk” neutropenic
patients both in adult and pediatric patient populations. Infection prevention (prophylaxis), infection control, and antimicrobial
stewardship are important aspects in the overall management of the febrile neutropenic patient.
KeywordsNeutropenia–Antimicrobial therapy–Low-risk–Febrile neutropenia–Fungal infection–Bacterial infection
12/2010: pages 95-103;
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Karen J Vigil,
Javier A Adachi,
Halim Aboufaycal,
Ray Y Hachem,
Ruth A Reitzel,
Ying Jiang,
Jeffrey J Tarrand,
Roy F Chemaly, Gerald P Bodey,
Kenneth V Rolston,
Isaam Raad
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ABSTRACT: Multidrug-resistant (MDR) Escherichia coli is a serious threat to cancer patients. We aimed to determine the risk factors associated with the development of MDR E coli bacteremia in cancer patients and the possibility of horizontal transmission.
We conducted a 1:2 case-control study of 58 patients with MDR E coli bacteremia. The patient's demographics, clinical characteristics, and antibiotic use were obtained. MDR E coli was defined as resistant strains to quinolones plus 1 of the following: piperacillin, ceftazidime, or cefepime. Repetitive sequence-based polymerase chain reaction (Rep-PCR) was used to identify DNA interstrain similarities.
Conditional multiple logistic analysis showed that admission to the hospital within the 30 days prior to infection and chemotherapy use were risk factors for infection with MDR E coli. Rep-PCR showed that, among the MDR E coli strains recovered, 48.6% showed >95% similarity, representing a possible clonal outbreak. Infection control measures were implemented and controlled this horizontal transmission.
Prior admission to the hospital and previous chemotherapy were independent risk factors of acquiring MDR E coli. Molecular fingerprinting techniques detected a possible nosocomial clonal outbreak of MDR E coli, which was aborted through infection control measures.
American journal of infection control 05/2009; 37(9):741-5. · 3.01 Impact Factor
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ABSTRACT: For the current study, the authors sought to determine whether administration of multiple-dose granulocyte-macrophage-colony-stimulating factor (GM-CSF) could improve response to standard 23-valent polysaccharide pneumococcal vaccine (PPV) in patients with chronic lymphocytic leukemia (CLL).
Patients were allocated randomly to receive PPV either alone or with 3 doses of GM-CSF (250 microg) given before or after vaccination. Serum was obtained before, 4 weeks after, and 12 weeks after vaccination for antibody determination. Thirty-two patients with CLL were given PPV. They were randomized to receive 3 doses of GM-CSF either before or after vaccination or to receive no GM-CSF.
A 4-fold rise in immunoglobulin G (IgG) to capsular polysaccharides from Streptococcus pneumoniae types 4, 6B, 9V, 14, 19F, and 23F occurred in <10% of patients in each of the 3 groups. There were no differences in geometric mean IgG levels in any of the 3 groups 4 weeks or 12 weeks after vaccination.
In patients with CLL, the response to pure polysaccharide pneumococcal vaccine was low despite immune enhancement with multiple doses of GM-CSF. In all patients, reactogenicity was minor.
Cancer 08/2008; 113(2):383-7. · 4.77 Impact Factor
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ABSTRACT: Polymicrobial infections account for ~15% of infections in immunocompromised patients with cancer. However, limited information exists regarding the spectrum and microbiology of these infections, even in severely neutropenic patients. Most studies describe only monomicrobial bloodstream infections in detail, and information regarding polymicrobial infections and nonbacteremic infections is often incomplete or not provided at all. The current lack of well-established definitions for various infections in the immunocompromised host, including pneumonia, neutropenic enterocolitis, and polymicrobial infections, probably plays an important role in the paucity of published information. In this review, we briefly describe the limited information available regarding polymicrobial infections in patients with cancer and address the need for establishing consensus definitions for site-specific polymicrobial infections in neutropenic and nonneutropenic patients. We anticipate that, as factual information regarding such infections becomes available, a more comprehensive understanding of the true scope and impact of these infections will emerge, leading to appropriate modifications in the diagnostic work-up and in the therapeutic approaches used in treating these patients.
Clinical Infectious Diseases 08/2007; 45(2):228-33. · 9.15 Impact Factor
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ABSTRACT: The increasing incidence of infections caused by multidrug-resistant Pseudomonas aeruginosa is a worldwide health problem. Because no new antipseudomonal agents are expected to be available in the near future, we evaluated the safety and efficacy of colistin, an old drug with bactericidal activity against this organism. We collected clinical and demographic data on 95 cancer patients diagnosed with infections caused by multidrug-resistant P. aeruginosa between January 2001 and January 2004 and treated with either colistin (colistin group) or at least one active antipseudomonal agent (a beta-lactam antibiotic or a quinolone) (control group). We compared the results obtained for both groups. Thirty-one patients had been treated with colistin and 64 had been treated with an antipseudomonal non-colistin-containing regimen. Compared with the control group, patients in the colistin group had a lower median age (52 and 62 years, respectively; P = 0.012) but were more likely to have had nosocomial infections (87% and 64%, respectively; P = 0.02). Twenty-five patients (81%) in the colistin group and 40 patients (63%) in the control group had an APACHE II score of >15 (P = 0.074). The overall clinical response rates were 52% in the colistin group and 31% in the control group (P = 0.055). Multiple logistic regression analysis showed that those patients treated with colistin were 2.9 times (95% confidence interval, 1.1 to 7.6 times) more likely than those in the control group to experience a clinical response to therapy (P = 0.026). Colistin therapy was at least as effective and as safe a beta-lactam antibiotic or a quinolone in the treatment of infections caused by multidrug-resistant P. aeruginosa and, hence, may be a useful or preferred alternative therapy for this infection in cancer patients.
Antimicrobial Agents and Chemotherapy 07/2007; 51(6):1905-11. · 4.84 Impact Factor
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Amar Safdar,
M Alma Rodriguez,
Luis E Fayad,
Gilhen H Rodriguez,
Barbara Pro,
Michael Wang,
Jorge E Romaguera,
Andre H Goy,
Fredrick B Hagemeister,
Peter McLaughlin, Gerald P Bodey,
Larry W Kwak,
Issam I Raad,
Robert B Couch
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ABSTRACT: In 27 patients randomized to receive commercial trivalent influenza vaccine (TIV) containing 15 microg of the hemagglutinin (HA) of influenza A (H3N2 and H1N1) and B virus or a recombinant vaccine (rHAO) containing 15, 45, or 135 microg of each HA, reactogenicity was minor. Among patients with similar prevaccination titers, 40% given 45 microg and 60% given 135 microg of rHAO developed an increase in influenza A/H3 neutralizing antibody levels; there were no increases in 4 given TIV. For each vaccine, the highest frequencies of increases in neutralizing antibody levels and the highest mean titers occurred in those given the 135- microg vaccine.
The Journal of Infectious Diseases 12/2006; 194(10):1394-7. · 6.41 Impact Factor
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ABSTRACT: Community respiratory viruses (CRVs) have been recognized as a potential cause of pneumonia and death among hematopoietic stem cell transplantation (HSCT) recipients and patients with hematologic malignancies. We reviewed the Microbiology Laboratory records dated from July 1, 2000, to June 30, 2002, to identify patients who had respiratory specimens positive for influenza, parainfluenza, respiratory syncytial virus, or picornavirus. We identified 343 infections among patients with underlying hematologic malignancies and HSCT. We collected data on type of disease, age, sex, type of infection, neutrophil and lymphocyte counts, therapy, and outcome. Influenza, parainfluenza, and respiratory syncytial virus accounted for most cases and were approximately equal in frequency. Most infections occurred predominantly among recipients of allogeneic transplants. Infection progressed to pneumonia in 119 patients (35%) and occurred with similar frequency for the 3 viruses. Patients at greatest risk for developing pneumonia included those with leukemia, those aged more than 65 years, and those with severe neutropenia or lymphopenia. Lack of respiratory syncytial virus-directed antiviral therapy (p=0.025) and age (p=0.042) were associated with development of respiratory syncytial virus pneumonia, and an absolute lymphocyte count<or=200 cells/mL (p=0.049) was associated with development of influenza pneumonia. The overall mortality rate for CRV pneumonia was 15%. The only independent predictor of fatal outcome was an absolute lymphocyte count<or=200 cells/mL (p=0.03) in patients with influenza pneumonia.HSCT recipients and patients with hematologic malignancies who develop upper respiratory infection due to CRVs should be considered for antiviral therapy of proven efficacy to reduce the risk of pneumonia and death.
Medicine 10/2006; 85(5):278-87. · 4.35 Impact Factor
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Journal of Antimicrobial Chemotherapy 09/2006; 58(2):478; author reply 479-80. · 5.07 Impact Factor
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ABSTRACT: We evaluated autopsy-proven invasive fungal infections (IFI) in patients with hematologic malignancies over three periods (1989-1993, 1994-1998, and 1999-2003). The autopsy rate declined significantly (67%-34%-26%, respectively p<0.0001). IFI were identified in 314 (31%) of 1017 autopsies. Most IFI (75%) were not diagnosed antemortem. The prevalence of invasive mold infections increased significantly (19%-24%-25% p=0.05) in parallel with the emergence of Zygomycetes (0.9%-4%-3%; p=0.03). The prevalence of all other IFI remained relatively constant. Among patients with invasive pulmonary aspergillosis, those with graft-versus-host disease had a histopathological pattern distinct from those with neutropenia. The complex and evolving epidemiology of IFI in severely immunocompromised patients is not well captured by current diagnostic methods.
Haematologica 07/2006; 91(7):986-9. · 6.42 Impact Factor
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ABSTRACT: There has been a rapid improvement in the overall prognosis for patients with acute myelogenous leukemia. The major determinant for this change is a progressive increase in the frequency of inducing complete hematological and clinical remissions from low levels to levels in excess of 50% of patients. The prognostic factors present prior to treatment which predict for a poor probability of response are advanced age, particularly in excess of 60 years, the presence of acute leukemia superimposed on a pre-existing preleukemic syndrome and the association of inevaluable cytogenetic studies. Further improvements in the probability of response requires both the development of better methods of supportive therapy for the host and a better understanding of the treatment of the oligoblastic or unusual leukemic patterns in elderly patients. The duration of remission has not significantly improved for the average patient being somewhere between 10 and 18 months. Analysis of those factors which predict for duration of remission indicate that entirely different variables are involved. Thus, the strategy of treatment for the patient in remission will almost certainly need to be different treatment of the patient with frank disease. Although remission duration has not been significantly prolonged for the average patient, it is observed that an increasing proportion of patients have prolonged remission duration. Careful analysis of duration of remission in patients indicates that the risk of relapse decreases progressively the longer a patient remains in this first remission. In a pilot study, it has been demonstrated that late intensification chemotherapy administered after patients are in remission for a year is associated with an even more favorable remission duration free of disease and free of continued chemotherapy. In this pilot study, there appears to be not only a progressive decrease in the risk of relapse the longer a patient is free of disease but relapse occurring after two years following the late intensification therapy has been very unusual. The small, but progressively increasing proportion of patients with prolonged survival is consistent with the pattern of survival seen in other malignant diseases where we now have convincing evidence of a detectable cure rate. These data support the concept that a small, but detectable, portion of the patients may have been rendered free of their disease. When it is considered that significant improvements in the treatment of acute myelogenous leukemia have only begun within the last 12 years, the rapid rate of change in prognosis for the majority of patients with acute leukemia and the prolonged survivorship observed in a small fraction of the patients provide important grounds for being optimistic about the possibility of long-term control of this disease.
Cancer 06/2006; 42(S2):874 - 882. · 4.77 Impact Factor
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Syed Wamique Yusuf,
Syed S Ali,
Joseph Swafford,
Jean-Bernard Durand, Gerald P Bodey,
Roy F Chemaly,
Dimitrios P Kontoyiannis,
Jeffery Tarrand,
Kenneth V Rolston,
Edward Yeh,
Issam I Raad,
Amar Safdar
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ABSTRACT: Endocarditis is uncommon in patients with cancer. The characteristics of culture-positive (CPE) and culture-negative endocarditis (CNE) in high-risk cancer patients are not known; therefore we sought to evaluate the disease characteristics in patients with endocarditis at a comprehensive cancer center. We retrospectively reviewed the transthoracic (TTE) and transesophageal (TEE) echocardiograms obtained from 654 consecutive cancer patients in whom endocarditis was suspected between 1994 and 2004. Endocarditis was confirmed in 45 (7%) of 654 patients using modified Duke University criteria based on information obtained from hospital records and computerized data systems. In 21 (95%) of 22 cases, TEE examinations were diagnostic, and 16 (42%) of 38 patients with initially nondiagnostic TTE studies had the diagnosis confirmed by TEE study; this difference between diagnostic TEE and initial nondiagnostic TTE was significant (p < 0.0001). Among the 26 (58%) patients with CPE, Staphylococcus aureus (35%) was the most common organism isolated, followed by coagulase-negative Staphylococcus species (23%). Eighteen (78%) of 23 patients with a central venous catheter had CPE, whereas only 8 (36%) of 22 patients without a central venous catheter had CPE (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.69-23.53; p < 0.006). Vegetations were larger in patients with CPE than in patients with CNE (median +/- standard deviation, 10 +/- 8.8 vs. 8.7 +/- 3.9 mm). Fifteen patients (58%) with CPE and 10 (53%) with CNE had embolic complications. We note that cutaneous and septic pulmonary emboli were more common in patients with CPE than in patients with CNE (31% vs. 11% and 15% vs. 0%, respectively), whereas embolic cerebrovascular and fatal embolic coronary events were more common in patients with CNE than in those with CPE (37% vs. 12% and 21% vs. 0%, respectively; p = 0.026). The 4-week endocarditis-attributable death rate did not differ significantly between the groups (CPE, 15% vs. CNE, 32%; p = 0.28). On stepwise multivariate regression analysis, patients with neutropenia (OR, 22.52; 95% CI, 2.25-225.48; p < 0.008) and those with embolic cerebrovascular events (OR, 17.07; 95% CI, 1.63-178.45; p < 0.01) had an increased probability of death due to endocarditis. The clinical spectrums of CPE and CNE differed in these patients with cancer. In patients with CNE, embolic cerebrovascular and fatal myocardial infarction were relatively common.
Medicine 03/2006; 85(2):86-94. · 4.35 Impact Factor
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ABSTRACT: Although gastrointestinal cytomegalovirus disease (GI-CMVd) is not common in cancer patients, it is associated with high morbidity and mortality. Herein, we review our 2-decade experience with GI-CMVd in such patient population at The University of Texas M.D. Anderson Cancer Center. Forty-seven patients were identified. Thirty-four patients (72%) had an underlying haematological malignancy, and 18 patients (38%) developed GI-CMVd following hematopoietic stem cell transplantation (HSCT). Nine (25%) of the 36 cancer patients with data available had AIDS. Upper-GI tract involvement was more common in patients with haematological malignancies than in those with solid tumours (P=0.02). Patients with AIDS were more likely to have colonic involvement than were those without AIDS (67% vs. 15%, P=0.006), and patients without AIDS were more likely to have gastric involvement (59% vs. 11%, P=0.01). The CMV-attributable mortality rate was 42%. Independent predictors of death by multivariate analysis included disseminated CMV and AIDS (P<0.01). The presentation of GI-CMVd varies according to the type of cancer, and AIDS. GI-CMVd is associated with a high mortality among cancer patients, particularly those with disseminated CMV disease or AIDS.
European Journal of Cancer 11/2005; 41(15):2268-79. · 5.54 Impact Factor
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ABSTRACT: Over the past several decades, there has been substantial progress in the management of patients with febrile neutropenia. However, the ever-changing patterns of infection, ecology, and antibiotic-resistance trends do not allow the development of treatment guidelines that could be applied universally. Hence, the institution's predominant pathogens and resistance patterns should guide the empirical choice of antimicrobials. Prompt initiation of antimicrobial therapy remains the gold standard. Monotherapy with the newer broad-spectrum antimicrobials has tended to replace the classic combination therapy. Empirical administration of glycopeptides, such as vancomycin, without documentation of a gram-positive infection is not favored. The development of risk-stratification models has allowed for identification of low-risk patients with additional treatment options, such as early discharge and exclusively outpatient treatment with oral antimicrobials. The initiation of empirical antifungal therapy in persistently febrile neutropenic patients has become common practice, especially recently, since the introduction of new, effective, less toxic antifungal drugs. It is hoped that the development of new nonculture-based diagnostic methods will allow for the early detection of invasive fungal infections and, thus, the replacement of empirical antifungal therapy with pathogen-specific, preemptive therapy.
Cancer 04/2005; 103(6):1103-13. · 4.77 Impact Factor
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ABSTRACT: Candidemia is a common cause of bloodstream infections in patients with cancer, with the majority of these infections being caused by a single Candida species. Studies of multiple-species candidemia (MSC) have rarely been reported.
The authors identified 33 patients with cancer who had candidemia (diagnosed between 1993 and 2000) caused by more than 1 Candida species. This group of 33 patients was compared with a control group of 66 patients with cancer who had C. albicans candidemia that arose soon before or soon after each case of MSC that was investigated in the current study.
Patients with MSC, compared with control patients, were more likely to have leukemia (33% vs. 8%; P = 0.001), to have had prolonged neutropenia before the onset of their infection (mean +/- standard deviation, 10 +/- 17 days vs. 3 +/- 6 days; P = 0.02), and to have received chemotherapy within 1 month before their infection (42% vs. 18%; P = 0.01). Patients with MSC also had higher Acute Physiology and Chronic Health Evaluation II scores at the onset of infection (score > or = 16, 45% vs. 26%; P = 0.05) and were more likely to have received previous antifungal prophylaxis compared with patients who had candidemia caused by C. albicans (33% vs. 11%; P = 0.006). The response of C. albicans candidemia to single-agent antifungal therapy was significantly better than that of MSC (69% vs. 35% P = 0.004).
In patients with cancer, MSC was more likely to occur as breakthrough candidemia, predominantly in those with leukemia and prolonged neutropenia, and was associated with suboptimal responses to single-agent antifungal therapy.
Cancer 11/2004; 101(8):1860-5. · 4.77 Impact Factor
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ABSTRACT: Invasive aspergillosis (IA) has emerged as a common cause of morbidity and mortality among immunocompromised patients. At The University of Texas M. D. Anderson Cancer Center (Houston, TX), Aspergillus terreus is second to A. fumigatus as the most common cause of IA. In the current study, the authors compared the risk factors and outcomes associated with IA caused by A. terreus and IA caused by A. fumigatus.
The authors retrospectively reviewed the medical records of 300 patients who received care at our institution between 1995 and 2001 and who had cultures that were positive for Aspergillus infection, including 90 patients whose cultures were positive for A. fumigatus and 70 patients whose cultures were positive for A. terreus.
Thirty-two patients with IA caused by A. terreus and 33 patients with IA caused by A. fumigatus were evaluated. The two groups were comparable in terms of age, gender, and underlying disease. Leukemia was the most common underlying malignancy (84%). More than 40% of patients in each group had undergone bone marrow transplantation. There was a trend toward a higher frequency of neutropenia among patients with IA caused by A. terreus (P = 0.12). IA caused by A. terreus was considered to be nosocomial in origin significantly more frequently compared with IA caused by A. fumigatus (P = 0.03). In vitro, A. terreus was found to be more resistant to amphotericin B (minimal inhibitory concentration [MIC90], 4.0 microg/mL) than to antifungal therapy (MIC90, 1.0 Hg/mL) in the isolates that were tested (< 50% of all isolates). The overall rate of response to antifungal therapy was 39% for patients with A. fumigatus infection, compared with 28% for patients with A. terreus infection (P = 0.43).
Despite the decreased in vitro susceptibility of A. terreus (relative to A. fumigatus) to amphotericin B, the two groups within the current patient population had comparably poor responses to amphotericin B preparation and somewhat improved responses to posaconazole.
Cancer 11/2004; 101(7):1594-600. · 4.77 Impact Factor
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ABSTRACT: To determine the need and appropriate timing of catheter removal in patients with candidemia, the records for 404 patients with cancer and central venous catheters (CVCs) who developed candidemia during the period of 1993-1998 were retrospectively reviewed. Of the total 404 cases of candidemia, 241 (60%) were due to a primary source, 111 (27%) were catheter related, and 52 (13%) were secondary cases of candidemia caused by a source other than the catheter. Multivariate analysis showed that catheter removal < or =72 h after onset improved response to antifungal therapy exclusively in patients with catheter-related candidemia (P=.04). Clinical characteristics that suggested a noncatheter source for the candidemia were disseminated infection (P<.01), previous chemotherapy (P<.01), previous corticosteroid therapy (P=.02), and poor response to antifungal therapy (P<.03). CVC removal < or =72 h after onset should be considered in patients with suspected catheter-related candidemia who have no evidence of dissemination, recent corticosteroid therapy, or chemotherapy.
Clinical Infectious Diseases 04/2004; 38(8):1119-27. · 9.15 Impact Factor
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ABSTRACT: To assess the spectrum and outcome of trichosporonosis (TS) in cancer patients, we reviewed the medical records of 17 such patients with TS. TS presented most commonly as fungemia (n = 10, including 7 with central-venous-catheter-related infection) and either pulmonary or soft tissue infection (n = 3, each). Most patients (65%) had acute leukemia, 11 (65%) had neutropenia, and 9 (53%) had received high doses of corticosteroids. 10 patients had breakthrough TS during therapy with at least 1 of the following: amphotericin B, fluconazole, itraconazole, and voriconazole. The 30-d crude mortality rate was 53%. Predictors of mortality by using univariate analysis included: high median APACHE II score (p < 0.01), use of high dose of corticosteroids (p = 0.01), and admission to the intensive care unit (p < 0.01). TS is associated with a high mortality rate in cancer patients. The spectrum of infection at our institution has shifted from a predominance of disseminated infection to CVC-related fungemias without evidence of tissue invasion.
Scandinavian Journal of Infectious Diseases 01/2004; 36(8):564-9. · 1.72 Impact Factor
