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ABSTRACT: Invasive pulmonary aspergillosis (IPA) is a life-threatening infection in immunocompromised patients. The outcome of such infections depends on early diagnosis and prompt initiation of therapy. The objective of the current study was to determine the significant predictive factors that characterize IPA in patients with cancer.
The clinical characteristics and computed tomography (CT) findings for 47 cases with IPA were retrospectively reviewed and compared with 49 controls (patients diagnosed on autopsy with nonfungal pneumonias). Data from all 96 patients were modeled using multivariate logistic regression. Subgroups of patients with common characteristics and outcomes were identified.
Leukemia, neutropenia, cavitation, and nodular lesions occurred significantly more often among cases than controls (P = 0.04, 0.004, 0.04, and 0.02, respectively). A quantitative scoring system was developed that could be used to identify patients as being at low, medium, and high risk for IPA.
IPA should be highly suspected in leukemia patients with profound neutropenia, pleuritic chest pain, and cavitary or nodular lesions detected on CT scan. These predictive factors can be used to indicate when early prophylactic and therapeutic antifungal interventions should be initiated.
Cancer 05/2006; 106(7):1581-6. · 4.77 Impact Factor
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ABSTRACT: We reviewed the epidemiology, clinical manifestations, and outcomes of 3 cases of chest tube-related empyema due to methicillin-resistant Staphylococcus aureus (MRSA). Antiseptic-impregnated chest tubes were inserted in cultures containing MRSA isolates from these 3 patients, and zone of inhibition were measured. Chest tube-related MRSA empyema might complicate tube thoracostomy, and coating the chest tube with antiseptic agents could prevent this complication.
Infection Control and Hospital Epidemiology 03/2006; 27(2):195-7. · 3.67 Impact Factor
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ABSTRACT: In the current era of multidrug-resistant organisms, the clinical spectrum of Streptococcus pneumoniae infection remains unclear, especially in immunosuppressed patients with cancer. We sought to define the characteristics of pneumococcal bacteremia in patients who were receiving care at a comprehensive cancer center. All consecutive episodes of S. pneumoniae bacteremia between January 1998 and December 2002 were evaluated retrospectively. One hundred thirty-five episodes of pneumococcal bacteremia occurred in 122 patients. Sixty-three (52%) of 122 patients had hematologic malignancies; the others had solid tumors. The median Acute Physiology and Chronic Health Evaluation II score was 14 +/- 5. Twenty-four episodes (18%) occurred during neutropenia (<500 cells/microL). Sixty-five patients (53%) were receiving antineoplastic therapy, and 36 (30%) were receiving systemic corticosteroids. Twelve (41%) of 29 hematopoietic stem cell transplant (HSCT) recipients had received transplantation within 12 months of the infection diagnosis; 11 patients had graft-versus-host disease (chronic in 10). In 27 episodes (22%), S. pneumoniae bacteremia was considered as a breakthrough infection. Nine (56%) of 16 hospital-acquired episodes of S. pneumoniae bloodstream infection occurred in patients with profound neutropenia, whereas 15 (13%) of 119 episodes of community-acquired infection occurred during neutropenia (p < 0.0002). In 91 episodes (67%), patients had radiographic evidence of pneumonia. Infected catheters were associated with 21 episodes (16%). Forty-eight (36%) of 135 isolates were not susceptible to penicillin (minimum inhibitory concentration [MIC] > or = 2 microg/mL); 9 (7%) showed intermediate susceptibility to ceftriaxone (MIC >0.5 and <2.0 microg/mL). Nineteen patients (16%) died within 2 weeks of diagnosis; 18 deaths were attributed to systemic pneumococcal infection. Univariate analysis showed no significant increase in the risk of short-term death in patients with infection due to penicillin non-susceptible organisms (OR [odds ratio], 1.47; 95% confidence intervals [CI], 0.53-4.05; p < 0.46), initially discordant treatment (OR, 1.0; 95% CI, 0.62-665.4; p < 0.16), presence of pneumonia (OR, 1.19; 95% CI, 0.39-3.62; p < 0.76), neutropenia (OR, 1.0; 95% CI, 0.28-4.09; p < 0.92), systemic corticosteroid use (OR, 1.96; 95% CI, 0.69-5.60; p < 0.21), or antineoplastic therapy (OR, 1.45; 95% CI, 1.52-4.05; p < 0.47). Similarly, patients with hematologic cancers compared to those with solid cancers (OR, 1.0; 95% CI, 0.49-3.70; p < 0.56) and recipients of HSCT compared to those with no history of transplantation (OR, 1.0; 95% CI 0.59-12.71; p < 0.20) did not have a less favorable outcome. In conclusion, most pneumococcal bloodstream infections were community acquired, although hospital-acquired infections were common in neutropenic patients. It is noteworthy that initially discordant therapy, penicillin non-susceptible S. pneumoniae, and other conventional predictors of unfavorable outcome were not associated with increased mortality rates in these high-risk patients with cancer.
Medicine 10/2005; 84(5):303-12. · 4.35 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: 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: Candida glabrata is an increasing cause of candidemia, especially at cancer and bone marrow transplant centers where fluconazole is used for antifungal prophylaxis. This yeast is less susceptible to fluconazole in vitro than is Candida albicans. We compared the characteristics of patients who had C. glabrata and C. albicans candidemia at a large cancer center.
We searched the microbiological laboratory reports and identified 116 cases of C. glabrata candidemia between 1993 and 1999. The 116 cases of C. albicans candidemia that occurred most closely in time (before or after each case of C. glabrata candidemia) served as the control group. Data were collected from patients' medical records.
When compared with patients who had C. albicans infection, patients with C. glabrata candidemia more often had an underlying hematologic malignancy (68 [59%] vs. 26 [22%], P = 0.0001), had an Acute Physiology and Chronic Health Evaluation (APACHE) II score > or =16 (55 [48%] vs. 28 [25%], P = 0.0002), and received fluconazole prophylaxis (57 [49%] vs. 8 [7%], P = 0.0001). Patients with C. albicans candidemia more often had concomitant infections (101 [87%] vs. 78 [67%], P = 0.0003) and septic thrombophlebitis (11 [10%] vs. 2 [2%], P = 0.01). Among patients treated with antifungal therapy, those with C. albicans candidemia had a significantly greater overall response to therapy (83/104 [80%] vs. 60/97 [62%], P = 0.005) and to primary therapy (74/104 [71%] vs. 45/97 [46%], P = 0.0003). Amphotericin B preparations were not more effective than fluconazole (19/45 [42%] vs. 20/38 [53%], P = 0.5) in patients with C. glabrata candidemia. Fluconazole was less effective against C. glabrata than against C. albicans (20/38 [53%] vs. 57/74 [77%], P = 0.008).
C. glabrata has emerged as an important cause of candidemia, especially among neutropenic patients who receive fluconazole prophylaxis.
The American Journal of Medicine 04/2002; 112(5):380-5. · 5.43 Impact Factor
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ABSTRACT: Background
Candida krusei is inherently resistant to fluconazole and is emerging as a frequent cause of fungemia in patients with hematologic malignant neoplasms.Objective
To determine the risk and prognostic factors associated with C krusei fungemia in comparison with Candida albicans fungemia in patients with cancer.Methods
Retrospective study of 57 cases of C krusei fungemia occurring at the M. D. Anderson Cancer Center, Houston, Tex, from 1989 to 1996. The C krusei cases were compared with 57 cases of C albicans fungemia with respect to demographics, underlying cancer, Acute Physiology and Chronic Health Evaluation II score, immunosuppression status, chemotherapy, and the use of central venous catheters, as well as fluconazole prophylaxis.Results
At our institution, C krusei accounted for 5% of fungemias during 1989 through 1992 and for 10% during 1993 through 1996. Patients with C krusei fungemia more often had leukemia than patients with C albicans (77% vs 11%; P = .02), whereas catheter-related infections were more common among patients with C albicans fungemia (42% vs 0%; P<.001). Patients with C krusei fungemia had a lower response rate (51% vs 69%; P = .05), largely because they more frequently were neutropenic and had disseminated infection. Mortality related to fungemia was 49% in the cases with C krusei vs 28% in C albicans. Multiple logistic regression analysis showed that persistent neutropenia (P = .02) and septic shock (P = .002) were predictors of poor prognosis.Conclusion
In neutropenic patients, C krusei fungemia is associated with high mortality. It should be suspected in patients with leukemia who are receiving fluconazole prophylaxis and should be treated aggressively with an amphotericin B regimen.
FOR MANY years, nearly all cases of candidemia were caused by Candida albicans. During the past decade, Candida tropicalis emerged as an important pathogen, especially among patients with cancer.1- 3 More recently, other Candida species have proved to be responsible for an increased proportion of candidemias, and Candida krusei has become one of the most frequent of these emerging pathogens, especially among patients with acute leukemia.2,4Candida krusei is inherently resistant to fluconazole, and many of the infections caused by this organism have been associated with the prophylactic or therapeutic use of this antifungal agent.5- 6 Since most institutions have had limited experience with C krusei fungemia, we reviewed all cases occurring at our institution during a 7-year period. A control group of patients with C albicans fungemia was selected to determine risk factors that were unique for the acquisition of C krusei fungemia.
Archives of Internal Medicine 160(17):2659-2664. · 11.46 Impact Factor
