RESUMEN
Records of 31 patients with cancer who did not have known human immunodeficiency virus infection and who developed culture-proven cryptococcosis during the period of 1989-1999 (incidence of 18 cases per 100,000 admissions) were retrospectively reviewed. Several presentations of cryptococcosis were seen, including pulmonary in 19 patients (13 of which were symptomatic), disseminated in 6, meningeal in 3, and other, less common manifestations in 3. Hematologic malignancy (in 20 patients [65%]) was the most common underlying disease. Lymphopenia was present in 19 patients (61%). Previous steroid use was noted in 16 patients (51%). The diagnosis of cryptococcosis was rarely suspected; lung and brain malignancy were frequent initial impressions. Cryptococcosis was diagnosed postmortem in only 2 cases (6%). In cases of both pulmonary and meningeal cryptococcosis, the yield of invasive diagnostic procedures was good. Antifungal treatment was heterogeneous, but only 18% of patients who received it had treatment failure. Fluconazole monotherapy was successful in 92% of patients. In conclusion, cryptococcosis is rare in patients with cancer and appears to have a relatively good diagnostic yield and therapeutic outcome.
Asunto(s)
Criptococosis/complicaciones , Criptococosis/epidemiología , Neoplasias/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Antifúngicos/uso terapéutico , Criptococosis/diagnóstico , Criptococosis/tratamiento farmacológico , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Nocardia bacteremia is very rare. We report 2 cases of central venous catheter-associated Nocardia bacteremia and review the literature. The limited clinical experience suggests that discontinuing the catheter and embarking on a relatively short course of appropriate antibiotics results in a good outcome.
Asunto(s)
Bacteriemia/microbiología , Cateterismo Venoso Central/efectos adversos , Nocardiosis/microbiología , Nocardia asteroides/aislamiento & purificación , Adulto , Bacteriemia/diagnóstico , Femenino , Humanos , Masculino , Nocardiosis/diagnósticoRESUMEN
BACKGROUND: Discrepancies between the severity of toxicities reported in early clinical trials and recent clinical experience with vancomycin have led to confusion regarding the need for routine serum vancomycin level monitoring and discontinuation of vancomycin when toxicities occur. Therefore, the authors examined the incidence, outcomes, and predictive factors of vancomycin-associated toxicities in general oncology practice with the goal of developing clinically relevant prediction rules and guidelines. METHODS: All 742 consecutive cancer patients who received vancomycin at a comprehensive cancer center during a 3-month period were followed prospectively for the development and outcome of phlebitis, rash, ototoxicity, and nephrotoxicity. Logistic regression was used to derive a multiple variable model of the risk of nephrotoxicity. A clinical prediction rule, the Nephrotoxicity Risk Score, was developed from the risk model and validated prospectively. RESULTS: Phlebitis occurred in 3% of patients (95% confidence interval [95% CI], 2-4%), predominantly those with recently inserted central venous catheters. Rashes occurred in 11% of patients (95% CI, 9-13%); however, all but 4 patients also were receiving beta-lactam antibiotics. Clinical evidence of ototoxicity developed in 6% of patients (95% CI, 4-9%) who were receiving vancomycin plus other ototoxic agents and only 3% of patients (95% CI, 2-5%) not receiving other ototoxic agents (P = 0.08). Nephrotoxicity occurred in 17% of patients (95% CI, 15-20%). Logistic regression revealed that factors associated with an increased risk of nephrotoxicity included administration of other mild to moderate (P = 0.01) or severely nephrotoxic agents (P < 0.001) or an acute physiology and chronic health evaluation (APACHE) score > 40 (P = 0.002). Elevated serum vancomycin peak levels did not reliably predict subsequent nephrotoxicity. CONCLUSIONS: Vancomycin-associated toxicities usually are mild and self-limiting. Some patients are at a significantly higher risk of nephrotoxicity but the authors believe these individuals can be identified reliably with the Nephrotoxicity Risk Index using information available at vancomycin initiation. Further testing of the Nephrotoxicity Risk Index is ongoing.
Asunto(s)
Antibacterianos/efectos adversos , Trastornos de la Audición/inducido químicamente , Riñón/efectos de los fármacos , Flebitis/inducido químicamente , Vancomicina/efectos adversos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Infecciones Bacterianas/tratamiento farmacológico , Farmacorresistencia Microbiana , Femenino , Humanos , Huésped Inmunocomprometido , Masculino , Persona de Mediana Edad , Neoplasias/terapia , Estudios Prospectivos , Análisis de RegresiónRESUMEN
BACKGROUND: The improved efficacy of imipenem over other beta-lactam antibiotics in the treatment of febrile neutropenic patients has been attributed to its broad spectrum of activity. METHODS: A prospective, randomized, clinical trial was performed comparing vancomycin 1 g every 12 hours plus imipenem/cilassatin 500 mg every 6 hours and the same dose of vancomycin plus aztreonam 2 g every 6 hours for empiric treatment of febrile episodes in neutropenic patients with cancer. RESULTS: The imipenem regimen cured 76% of the 148 evaluable episodes compared with a 67% cure rate for the 152 episodes treated with the aztreonam regimen (p = 0.1). Most of the polymicrobial infections (77% or 10/13) treated with the imipenem responded, whereas only 38% (5/13) of these infections responded to the aztreonam regimen. Although the cost of the imipenem regimen was less than the cost of the aztreonam regimen, it was associated significantly more with skin rashes (12/194 vs 3/189, p = 0.02). In a multivariate analysis, a poor outcome was independently associated in both instances with the persistence of neutropenia and the presence of pneumonia (p < 0.001). CONCLUSIONS: Overall, in a multifactorial analysis that included efficacy, toxicity, and cost, the imipenem and aztreonam regimens were comparable.
Asunto(s)
Infecciones Bacterianas/tratamiento farmacológico , Quimioterapia Combinada/uso terapéutico , Fiebre/tratamiento farmacológico , Neoplasias/complicaciones , Neutropenia/tratamiento farmacológico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Aztreonam/uso terapéutico , Infecciones Bacterianas/complicaciones , Femenino , Fiebre/etiología , Bacterias Gramnegativas/efectos de los fármacos , Bacterias Grampositivas/efectos de los fármacos , Humanos , Imipenem/uso terapéutico , Recuento de Leucocitos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Análisis Multivariante , Neoplasias/sangre , Neutropenia/complicaciones , Neutrófilos/citología , Estudios Prospectivos , Vancomicina/uso terapéuticoAsunto(s)
Trasplante de Médula Ósea/efectos adversos , Legionella pneumophila/aislamiento & purificación , Enfermedad de los Legionarios/microbiología , Pericarditis/microbiología , Antibacterianos , Quimioterapia Combinada/uso terapéutico , Humanos , Legionella pneumophila/efectos de los fármacos , Enfermedad de los Legionarios/tratamiento farmacológico , Leucemia Linfocítica Crónica de Células B/terapia , Masculino , Persona de Mediana Edad , Pericarditis/tratamiento farmacológicoRESUMEN
Osteomyelitis in uncommon locations can present unusual diagnostic difficulties. A patient with primary sternal osteomyelitis who presented with pain over the right supraclavicular area and a radiologic picture of a pleural-based right upper lung mass is discussed. A triple-phase bone scan was consistent with the diagnosis, and a needle aspiration of the mass revealed a staphylococcal abscess. Percutaneous drainage of the contiguous abscess and a prolonged course of antibiotic therapy cured the infection.