An Audit of Efficacy and Toxicity of Teicoplanin Versus Vancomycin in Febrile Neutropenia: Is the Different Toxicity Profile Clinically Relevant?

Abstract Background: Glycopeptides are often used for persistent fever in neutropenic patients. This study compares efficacy and toxicity of teicoplanin and vancomycin. Patients and Methods: Hundred consecutive neutropenic patients with hematological malignancies and persistent fever after 72 h of first-line antibiotic therapy (91% piperacillin/tazobactam) were treated with teicoplanin (800 mg on day 1, then 400 mg/day) + piperacillin/tazobactam + gentamicin from 08/96 to 09/00 (group T) or with vancomycin (2 g/day) + meropenem + levofloxacin from 10/00 to 04/02 (group V). Success was defervescence (≥ 7 days) in absence of any sign of continuing infection. Nephrotoxicity was monitored daily as increase in serum creatinine. Results: Fifty patients were analyzed in each group. Efficacy was evaluated in patients with piperacillin/tazobactam as first-line therapy only. Treatment was successful in 76% in group T (n = 42) and 59% in group V (n = 49), p = 0.118. Toxicity was evaluated in all patients. The median increase of creatinine was 11% (interquartile range 0%–30%) in group T and 17% (0%–74%) in group V, p = 0.062. In patients who received concomitant amphotericin B (given for 7 days and 6 days, respectively, p = 0.525), median creatinine increased from 0.9 mg/dl (0.8–1.1) to 1.2 mg/dl (0.9–1.5) in group T and from 0.9 mg/dl (0.8–1.08) to 1.55 mg/dl (1.33–2.23) in group V (p < 0.001). This led to a doubling of creatinine in 2/23 (9%) patients of group T and in 9/16 (56%) patients of group V (p = 0.003). A multivariate analysis revealed that concomitant use of amphotericin B (p < 0.001) and treatment with vancomycin (p = 0.002) were independently associated with nephrotoxicity. Conclusion: Teicoplanin and vancomycin were comparably effective in patients with neutropenia and persistent fever, but – if combined with amphotericin B – vancomycin was significantly more nephrotoxic than teicoplanin.     

Piperacillin/tazobactam vs ceftazidime in the treatment of neutropenic fever in patients with acute leukemia or following autologous peripheral blood stem cell transplantation: a prospective randomized trial

Piperacillin/tazobactam was compared with ceftazidime for the empirical treatment of febrile neutropenia in patients with acute leukemia or following autologous peripheral blood stem cell transplantation. Owing to inclusion criteria, it was possible for the same patient to be randomized several times. A total of 219 individual patients were admitted to a prospective randomized clinical study: 24 patients were included twice. Patients (23.5%) remained afebrile. Patients who developed febrile neutropenia were randomized to receive intravenous ceftazidime (n = 74 patients, group I) or piperacillin/tazobactam (n = 87 patients, group II). Response to first-line antibiotic treatment was seen in 55% (group I) and 53% (group II). After the addition of vancomycin, a further 19% (group I) and 24% (group II) of the patients became afebrile. Causes of fever were: microbiologically documented infection in 36 and 34 patients of group I and II; Clostridium difficile in eight and 12 patients of group I and II, and fever of unknown origin in 30 and 41 patients of group I and II. One patient died in each group. Single-agent therapy with piperacillin/tazobactam is as effective as ceftazidime in the treatment of neutropenic fever and is well tolerated. Direct and indirect costs of both treatment regimes are equivalent.     

Respiratory tract infection caused by bacteria (non-Mycobacterium) and their antibiogram in HIV-positive patients

Abstract. This study was undertaken from 1995-2000 to investigate the cause of respiratory tract infection among 481 patients with human immunodeficiency virus (HIV) at Siriraj Hospital, Bangkok, Thailand. The positive rate of bacterial pathogens was 38.46%. Pseudomonas aeruginosa appeared to be the most common pathogen (32.97%), followed by Staphylococcus aureus (18.92%), Klebsiella pneumoniae (10.81 %), Haemophilus influenzae (7.57%), and Acinetobacter baumannii (5.95%). P. aeruginosa was sensitive to netilmycin, amikacin, imipenem, meropenem, cefoperazone/sulbactam, piperacillin/tazobactam, and gentamicin (67-84%). S. aureus was sensitive to vancomycin and teicoplanin (100%).     

Piperacillin plus amikacin vs. piperacillin plus amikacin plus teicoplanin for empirical treatment of febrile episodes in neutropenic patients receiving quinolone prophylaxis.

A prospective, randomized trial was initiated to evaluate the efficacy of two antibiotic regimens, differing in the agent included with activity against gram-positive bacteria, for the empirical treatment of febrile episodes in neutropenic patients with hematologic malignancies (group 1, piperacillin plus amikacin; group 2, piperacillin plus amikacin plus teicoplanin). After 72 hours of therapy, patients in group 1 who were still febrile were administered teicoplanin and those in group 2 were administered amphotericin B. A total of 158 evaluable episodes were observed within 8 months. The success rate was 50.6% in group 1 and 60% in group 2. The response rate among patients who did not respond to the original regimen increased to 86.7% with the addition of teicoplanin (group 1) and to 90% with the addition of amphotericin B (group 2). There were 86 unexplained febrile episodes and 56 documented episodes of bacteremia (34 caused by gram-positive organisms). Our results indicate that teicoplanin is safe, well tolerated, and effective for the treatment of documented episodes of gram-positive bacteremia and as an empirical agent. The inclusion of teicoplanin in the initial empirical regimen appears unnecessary if a combination of antibiotics active against gram-positive organisms is used, unless infections are due to oxacillin-resistant staphylococci.     

Cost comparison of linezolid versus vancomycin for treatment of complicated skin and skin-structure infection caused by methicillin-resistant Staphylococcus aureus in Quebec

BACKGROUND:

In Canada, complicated skin and skin-structure infection (cSSSI) caused by methicillin-resistant Staphylococcus aureus (MRSA) is usually treated with antibiotics in hospital, with a follow-up course at home for stable patients. The cost implications of using intravenous and oral linezolid instead of intravenous vancomycin in Canadian clinical practice have not been examined.

OBJECTIVES:

To evaluate the potential treatment cost impact for the Quebec health care system of linezolid versus vancomycin for MRSA-related cSSSI therapy, using a net impact analysis approach.

METHODS:

Health care resource use associated with linezolid and vancomycin therapy was estimated for patients in Quebec, based on expert opinion. Costs were assigned to health care resources (antibiotics, medical supplies, laboratory testing and health care professional time) based on unit prices. The base-case analysis assumed 14 days of antibiotic treatment for both agents; five days in hospital followed by nine days at home. Therapy duration, length of inpatient treatment and discharge rates were varied in sensitivity analyses.

RESULTS:

Antibiotic costs were higher for linezolid than for vancomycin, for both inpatient ($874 versus $144, respectively) and outpatient therapy ($1,356 versus $1,242, respectively). Compared with vancomycin, lower costs for antibiotic preparation, administration and monitoring of linezolid offset drug acquisition costs. Total treatment costs were $3,850 for linezolid versus $5,189 for vancomycin. Results were sensitive to the number of treatment days spent at home and the discharge rate.

CONCLUSION:

Using linezolid instead of vancomycin to treat MRSA-related cSSSI, for hospital and home courses combined, may reduce health care resource utilization and costs in Quebec.     

Vancomycin as part of initial empirical antibiotic therapy for febrile neutropenia in patients with cancer: pros and cons.

Gram-positive organisms predominate as the bacterial pathogens identified in episodes of febrile neutropenia. This has led to increased use of antibiotics with efficacy against gram-positive organisms (often vancomycin) as part of empirical antibiotic regimens for treating febrile neutropenia. Among 101 children randomized to receive amikacin, ticarcillin, and vancomycin or ticarcillin/clavulanate and amikacin along with vancomycin placebo, treatment success in those treated with vancomycin was higher (85% vs. 62%). In 1990, the European Organization for Research and Treatment of Cancer-National Cancer Institute of Canada Clinical Trials Group compared amikacin and ceftazidime with and without vancomycin and concluded that there was no need to include vancomycin in initial empirical antibiotic therapy. Results from another study and a retrospective review of a large clinical trial also support the previous conclusion. In 1999, most experts in the field recommend vancomycin not be part of the initial empirical therapy regimen for treating febrile neutropenia in patients with cancer.     

Vancomycin-induced neutropenia resolves after substitution with teicoplanin.

Neutropenia is an uncommon adverse effect associated with prolonged vancomycin therapy. Neutrophil counts normally recover after discontinuation of vancomycin in this situation, but treatment options are needed for those patients who require ongoing antibiotic therapy. We describe a case of vancomycin-induced neutropenia in which the neutropenia resolved after vancomycin was replaced by the structurally related compound teicoplanin.     

Teicoplanin in the treatment of Gram-positive bacteraemia in neutropenic patients

S ummary The increasing incidence of bacteraemia caused by Gram-positive bacteria in neutropenic patients prompted the authors to evaluate, in a prospective trial, the role of teicoplanin in the treatment of this infection. Over a 15-month period. 76 cases of bacteraemia (out of 265 evaluable episodes of fever) were observed at the Division of Haematology. University La Sapienza. Kome. Of the 76 cases studied, 46 (60%) were caused by Gram-positive bacteria and 28 (37%) were caused by Gram-negative bacilli. All febrile episodes were treated randomly and empirically with piperacillin plus amikacin with or without teicoplanin. Overall, 41 (54%) of the 76 cases of bacteraemia responded to the initial antibiotic regimen: with subsequent modifications the response rate rose to 96%.
In the treatment of Gram-positive bacteraemia. first-line administration of teicoplanin was found to be associated with early defervescence and with a significantly higher rate of success without modification of treatment (P < 0.01). Addition of teicoplanin as second-line therapy produced a favourable outcome in 12 (70%) out of 17 cases of bacteraemia unresponsive to the initial piperacillin + amikacin regimen. No cases of Gram-positive bacteraemia associated with septic shock or adult respiratory distress syndrome were observed in either treatment group. Only two late deaths were observed, and these occurred in patients with streptococcal septicaemia who were not receiving early teicoplanin.
The above data do not endorse the use of glycopeptide antibiotics in the early treatment of fever in neutropenic patients: rather, these compounds should be reserved for proven or presumed Gram-positive infections which do not respond to initial beta-lactam/aminoglycoside treatment.     

Blood stream infections throught the entire course of acute lymphoblastic leukemia treatment

The incidence, type and mortality of bacteremias were evaluated in a pediatric patient cohort, during the entire course of treatment for acute lymphoblastic leukemia (ALL). Eighty-six patients with newly diagnosed ALL were studied. A bacteremic episode was defined as blood isolation of a pathogen in the presence of clinical symptomatology of septicaemia. Bacteremias were analyzed according to the treatment element being delivered and the degree of neutropenia. A central venous catheter (CVC) was inserted at diagnosis in all patients. Fifty-two episodes of bacteremias were encountered in 38/86 (44%) patients, while 48/86 patients had no positive blood culture. Three out of the 38 patients had bacteremia and CVC area infection, simultaneously. Most blood stream infections (29/52, 56%) were documented during the induction phase. Isolated Gram-positive organisms were 48%, Gram-negative 50% and 2% of the positive blood cultures represented fungaemias. The most common Gram-positive isolates were Staphylococcus species (N=22) and the commonest Gram-negative isolated pathogens were Escherichia coli and Pseudomonas aeruginosa. The majority of bacteremias (75%) occurred during neutropenia. The initial antibiotic treatment was ceftazidime or piperacillin/tazobactam and amikacin or tobramycin. CVC was not removed in the majority of bacteremias (94%). No infection related fatality was recorded. Bacteremias constituted a severe and common complication in our patient cohort. However, infection-related fatality rate was negligible, most probably due to the prompt initiation of broad coverage antimicrobial therapy.     

Costs of high-dose salvage therapy and blood stem cell transplantation for resistant-relapsed malignant lymphomas in a southern Italian hospital

BACKGROUND AND OBJECTIVE: Analysis of costs of high technological procedures such as peripheral blood stem cell (PBSC) autotransplantation in lymphomas are generally finalized at disclosing whether the improvement of survival in a subset of patients is cost effective and whether the cost of the procedure could be reduced. With the aim of revealing a possibility of reducing costs with respect to conditions of safety, we present our experience with PBSC autotransplantation in a particularly poor prognosis subset of patients with lymphoma. DESIGN AND METHODS: The expenses are analyzed for groups of cost and main resources necessary at unitary cost are considered separately. Groups of cost include various phases of the PBSC autotransplantation such as preparative procedures, execution of myeloablative therapy, reinfusion of CD34 cells, supportive therapy after reinfusion until discharge of the patient, general support for the management of patient. All costs are calculated according to 1997 prices and salaries and reported in dollars. The analysis was conducted on 21 patients with lymphoma resistant to other therapies treated by myeloablative therapy and PBSC autotransplantation in an hematologic unit in an open ward; the assistance was provided by staff not exclusively dedicated to bone marrow transplant procedures, with some help from a family member. RESULTS: The PBSC procedure, including all phases, costs from $17,761.9 to $18,259.9 depending on the type of myeloablative therapy employed; the mean cost was $18,092.6. The preparative phase with mobilization of CD34 cells, cryopreservation and reinfusion costed $3,538.7 (19.6% of the total cost); a major cost of this phase was cryopreservation and CD34 manipulation ($857.1). The second phase with myeloablative therapy and reinfusion of CD34 cells had a mean cost of $2,785.9 (15.4% of the total cost); a major cost of this phase was the hospitalization ($1,119.8). The third phase of patient's support after treatment had a total cost of $7,649 (42.3% of the cost of the total procedure) with the major cost being due to hospitalization ($2,571) calculated on a mean of 15 days after the reinfusion of CD-34. The last group of costs, including management support, accounted for $4,119 (22.7%) with a major cost being amortization of the structure ($1,600). The general cost for nurse's assistance to the patient was $1,355.1 (7.5%). INTERPRETATION AND CONCLUSIONS: A procedure of PBSC autotransplantation in resistant lymphoma is affordable without the strict precautions generally given in intensive care units. This provides a substantial reduction of expenses because of the low number of specifically trained staff members and the generally low cost of the necessary supplies. Before, however, proposing PBSC autotransplantation in most patients with resistant lymphoma, an evaluation of whether costs could be further reduced and whether the procedure has a cost benefit impact is needed.     

Piperacillin or ticarcillin plus amikacin: A double-blind prospective comparison of empiric antibiotic therapy for febrile granulocytopenic cancer patients

Piperacillin plus amikacin was compared in a prospective randomized double-blind trial with our standard regimen of ticarcillin plus amikacin as empiric therapy of fever in patients with granulocytopenia. Profound persistent granulocytopenia (fewer than 100/μl polymorphonuclear leukocytes without a rise during therapy) was present in 60 percent of the patient trials in both treatment groups. Of 38 microbiologically and clinically documented infections treated with piperacillin plus amikacin, 22 (58 percent) showed improvement. Of 34 microbiologically and clinically documented infections treated with ticarcillin plus amikacin, 19 (56 percent) showed improvement. There was no difference in response between groups according to the site of infection or infecting pathogen. Toxicity was minimal, with an equivalent incidence of immediate reactions, nephrotoxicity and superinfection. Patients receiving ticarcillin plus amikacin became colonized with more resistant gram-negative bacilli (17) than did those receiving piperacillin plus amikacin (3). Despite the monosodium structure of piperacillin, hypokalemia was not reduced for patients who received piperacillin plus amikacin. Although piperacillin has a wider in vitro antibacterial spectrum than ticarcillin, the clinical efficacy and toxicity of the combination of piperacillin plus amikacin were similar to those of ticarcillin plus amikacin as empiric therapy.     

Antibiotic prophylaxis with teicoplanin on alternate days reduces rate of viridans sepsis and febrile neutropenia in pediatric patients with acute myeloid leukemia

Intensive chemotherapy directed against acute myeloid leukemia of childhood is followed by profound neutropenia and high risk for bacterial and fungal infections, including viridans group streptococci as a common cause for gram-positive septicemia. Few retrospective studies have shown the efficacy of various antibiotic prophylactic regimens in children. We retrospectively studied 50 pediatric patients treated on the AML-BFM 2004 protocol between 2005 and 2015 at St. Anna Children’s Hospital and assessed the effect of antibiotic prophylaxis on the frequency of febrile neutropenia and bacterial sepsis. Fifty pediatric patients underwent 199 evaluable chemotherapy cycles. Viridans sepsis occurred after none of 98 cycles with prophylactic administration of teicoplanin/vancomycin in comparison to 12 cases of viridans sepsis among 79 cycles without systemic antibacterial prophylaxis (0 vs. 15 %, p?<?0.0001). In addition, there were significantly fewer episodes of febrile neutropenia in the teicoplanin/vancomycin group (44 % vs. no prophylaxis 82 %, p?<?0.0001). Severity of infection seemed to be worse when no antibiotic prophylaxis had been administered with a higher rate of intensive care unit treatment (0/98, 0 %, vs. 4/79, 5 %, p?=?0.038). So far, no increase of vancomycin-resistant enterococcus isolates in surveillance cultures was noticed. Antibiotic prophylaxis with teicoplanin (or vancomycin) appears safe and feasible and resulted in eradication of viridans sepsis and decreased incidence of febrile neutropenia in pediatric AML patients. The possibility to administer teicoplanin on alternate days on an outpatient basis or at home could contribute to patient’s quality of life and decrease health care costs.     

Risk factors of septic shock in patients with hematologic malignancies and Pseudomonas infections

Pseudomonas is a clinically significant and opportunist pathogen, usually associated in causing high mortality nosocomial infections. The aim of this study was to determine the risk factors associated with septic shock in patients diagnosed with hematologic malignancies and Pseudomonas infections. A total of 80 Pseudomonas isolates (77 Pseudomonas aeruginosa) were collected from 66 patients aged 2-64 years: 52 with acute leukemia (79%), 7 with lymphoma (10.5%), and 7 with other hematologic disorders (10.5%), between 2001 and 2009. The median age of the patients was 30 years. Isolates were collected mostly from bloodstreams (45%) and skin lesions (31.5%). The median time for microbiologic documentation was 8 days (range 0-35 days) from onset of neutropenia. At least 11 patients (16.6%) had recurrent (≥2) infections. The clinical symptoms observed were skin lesions (34%), diarrhea (20%), isolated fever (18%), and respiratory symptoms (14%). The isolates tested were found resistant to piperacillin/tazobactam (43%), ceftazidime (31%), imipenem-cilastatin (26%), ciprofloxacin (25%), and amikacin (26%). Septic shock occurred in 16.2% of episodes (13/80). Crude mortality due to septic shock occurred in 19.6% of patients (13/66). The median time for response to antibiotic therapy in the remaining 80.4% of patients (53/66) was 2.5 days. Univariate analysis revealed that factors associated with septic shock were: fever for ≥3 days in patients on antibiotic therapy (P = 0.019), serum lactate >5 mmol (P = 0.05), hemoglobin level <50 g/l (P = 0.042), hypoproteinemia <50 g/l (P = 0.01), procalcitonin >10 ng/ml (P = 0.031), and hypophosphatemia (P = 0.001). Multivariate analysis revealed that hypophosphatemia (P = 0.018), hypoproteinemia (P = 0.028), and high serum lactate (P = 0.012) are significant factors, independently associated with increased risk of septic shock in patients with hematologic malignancies and Pseudomonas infections.     

Out-patient management of acute myeloid leukemia after consolidation chemotherapy. Role of a hematologic emergency unit.

BACKGROUND AND OBJECTIVE: Increasing attention to quality of life and to health care costs has recently induced several cancer centers to change in-patient management into an out-patient setting even during high risk phases of disease. The aim of this prospective study was to evaluate feasibility and safety, as well as clinical characteristics, of out-hospital management of AML patients during their post-consolidation phase. DESIGN AND METHODS: All patients who were treated over a three year period by the three following protocols were included in the study: AML10 EORTC/GIMEMA for patients with AML, except for APL, aged 60 years; AIDA GIMEMA for APL patients. All patients submitted to the AML10 and AML13 protocols and those patients submitted to the AIDA protocol with difficult peripheral vein access had a central venous catheter (CVC) sited. Patients treated as in-patients were discharged at the end of consolidation chemotherapy provided they were in a good clinical condition. They were routinely evaluated on an out-patient basis twice weekly. In the event of any complication they were referred to the Emergency Unit of our Department dedicated to out-patients with hematologic diseases. RESULTS: One hundred and eleven patients with AML were eligible for intensive chemotherapy. After achievement of complete remission they received a total of 133 consolidation courses and in 127 instances they were followed on an out-patient basis during the aplastic phase. There were 69 cases (54%) of rehospitalization, 68 because of fever and only one because of severe anemia. Rehospitalization occurred in 90%,70% and 38% of courses in AML10, AML13 and AIDA protocols, respectively. Only one patient died: the cause of death was a brain hemorrhage. Coagulase negative staphylococci and viridans streptococci were the organisms most frequently isolated from blood. Most coagulase negative staphylococci were isolated in patients submitted to AML10 and AML13 protocols, who had an indwelling CVC. Empiric once-a-day antibacterial therapy with ceftriaxone and amikacin was effective in 75% of the cases and made early discharge possible in 28% of the cases with antibiotic therapy continued in an out-patient setting. Overall, patients were managed out of the hospital for 66% of the period of post-consolidation neutropenia (77%, 48% and 50% of the post-consolidation neutropenia period in patients treated with AIDA, AML10 and AML13 protocols, respectively). INTERPRETATION AND CONCLUSIONS: Thanks to the availability of an emergency unit specifically dedicated to out-patients with hematologic diseases, selected out-hospital management of AML patients during post-consolidation cytopenia is a feasible, well accepted and cost-saving option, and can contribute to lower the risk of developing severe nosocomial infections. The empiric therapy with once-a-day ceftriaxone plus amikacin was effective, with the exception of staphylococcal infections, and made it possible to discharge patients early to continue treatment in an out-patient setting.     

Vancomycin-resistant Enterococcus faecium infection in patients with hematologic malignancy: patients with acute myeloid leukemia are at high-risk

BACKGROUND: Vancomycin-resistant enterococci (VRE) are significant nosocomial pathogens in patients with hematologic malignancy. Identification of risk factors for infection is necessary for targeted prevention and surveillance. OBJECTIVES AND METHODS: An outbreak of VRE infection occurred at a tertiary cancer hospital between 1 August 2003 and 30 June 2005. Infection control measures recommended by the Society for Healthcare Epidemiology of America were used throughout the outbreak period. A matched case-control study was performed to identify risk factors for VRE infection. RESULTS: Fourteen VRE infections (13 episodes of bacteremia, one urinary tract infection) occurred a median of 10.5 d following hospital admission. All were due to Enterococcus faecium vanB. Univariate analysis identified the following variables to be significantly associated with VRE infection: presence of neutropenia, neutropenia >or=7 d, underlying diagnosis of acute myeloid leukemia (AML), and receipt of vancomycin, metronidazole or carbapenem antibiotic therapy in the 30 d prior to infection. On multivariate analysis, an underlying diagnosis of AML [odds ratio (OR), 15.00; P = 0.017] and vancomycin therapy during the previous 30 d (OR, 17.96; P = 0.036) were retained as independent risk factors for infection. CONCLUSIONS: Risk stratification for development of VRE infection is possible for patients with hematologic malignancy. Patients with AML represent a high-risk population, and targeted prevention strategies must include improved antibiotic stewardship, particularly judicious use of vancomycin therapy.     

Aztreonam or gentamicin combined with piperacillin as empiric antibiotic therapy during neutropenia of patients with hematologic diseases]

Fourty-two febrile episodes of 32 patients with hematologic disease during neutropenia were treated with two randomly assigned antibiotic combinations of either piperacillin plus gentamicin or piperacillin plus aztreonam. Eleven of the 22 febrile episodes treated with piperacillin plus gentamicin and 12 of the 20 febrile episodes treated with piperacillin plus aztreonam responded. Addition of cefamandole to non-responders improved the outcome in 2 of the 16 febrile episodes. Mean nadir leucocyte count, age, sex, and underlying disease were not significantly different in both groups. Side effects were tolerable in both groups, although 1 patient treated with piperacillin plus gentamicin showed severe renal impairment. Piperacillin plus aztreonam is as effective as piperacillin plus gentamicin as an empiric antibiotic combination in the treatment of febrile episodes with hematologic disease during neutropenia.     

A randomized study of teicoplanin plus ciprofloxacin versus gentamicin plus piperacillin for the empirical treatment of fever in neutropenic patients

S ummary We compared the combination of teicoplanin plus ciprofloxacin with gentamicin plus piperacillin for the empirical treatment of fever in 80 neutropenic patients. A favourable clinical response rate was achieved in 28/38 (74%) patients receiving teicoplanin plus ciprofloxacin and in 17/ 35 (49%) of those receiving gentamicin plus piperacillin (P = 0.05). Microbiologically documented infections accounted for 55% of febrile events. When these episodes were analysed separately, response to teicoplanin plus ciprofloxacin remained unchanged at 74% whereas only 35% patients responded to gentamicin and piperacilin (P=0.034). Gram-positive organisms accounted for 78% bacterial isolates with Staphylococcus epidermidis the most common pathogen. Ten out of 12 (83%) Staph. Epidermidis infections resolved when treated with teicoplanin and ciprofloxacin as compared with a response rate of only two out of eight (75%) with gentamicin and piperacillin (P = 0.032). The combination of teicoplanin and ciprofloxacin was associated with no severe drug-related adverse events: by contrast, two patients receiving gentamicin plus piperacilin were withdrawn owing to adverse drug reactions, one with acute renal failure and one following a severe allergic reaction to piperacillin. We conclude that teicoplanin with ciprofloxacin is more effective than gentamicin plus piperacillin for the empirical treatment of febrile neutropenic patients. The high incidence of Gram-positive infection in our unit probably justifies the use of a specific anti-Gram-positive agent in the first-line antibiotic regimen.     

广州市胸科医院结核重症监护室患者常见病原菌分布及耐药性分析

目的分析广州市胸科医院结核重症监护室(ICU)患者常见病原菌的分布及耐药情况,为重症感染患者的初始经验性用药提供临床依据。方法回顾性分析2018年ICU患者送检标本培养出的病原学分布情况及多重耐药菌的药敏结果。结果1、共检出病原菌599株,包括细菌433株,其中多重耐药菌占比72.75%(315株);真菌166株,主要为热带假丝酵母菌(31.33%)、光滑假丝酵母菌(28.31%)及曲霉菌(10.84%)。2、临床检出的315株多重耐药菌中,革兰阴性杆菌占87.62%,其中鲍曼不动杆菌占44.76%,肺炎克雷伯杆菌占23.81%,铜绿假单胞菌占10.79%;革兰阳性球菌占12.38%,其中表皮葡萄球菌占2.86%,溶血葡萄球菌占2.54%,屎肠球菌占2.22%,金黄色葡萄球菌占1.27%。3、临床分离的革兰阴性杆菌对哌拉西林/他唑巴坦、头孢哌酮/舒巴坦、左氧氟沙星、亚胺培南的耐药情况严重,对替加环素、妥布霉素、阿米卡星的耐药性相对较低,未发现耐黏菌素菌株;革兰阳性球菌总体对头孢洛林、利奈唑胺、万古霉素、替考拉宁、替加环素、达托霉素的敏感性较好。结论结核重症监护室检出的病原菌以多重耐药菌及真菌常见,经验性用药需考虑耐药分布情况及真菌感染的可能性。     

Susceptibility testing of Pseudomonas aeruginosa by the Vitek 2 system: a comparison with Etest results

P. aeruginona infections need accurate antimicrobial susceptibility data, as treatment mainly relies on antibiotic efficiency in debilitated patients. Vitek 2, a popular automated susceptibility testing method, was compared with Etest to assess its reliability on 150 Belgian P. aeruginonas isolates. Vitek 2 and Etest exhibited a high degree of concordance, but some discrepancies in clinical category were evident for cefepime (high minor and borderline very major error rate) and for piperacillin/tazobactam (high very major error rate). Vitek 2 appears to yield valuable information to the clinician concerning the antimicrobials amikacin, ceftazidime, ciprofloxacin and meropenem, in the setting of pseudomonas infection. For cefepime and piperacillin/tazobactam, a confirmatory testing by means of disk diffusion is worth considering.     

Ceftazidime plus teicoplanin versus ceftazidime plus amikacin as empiric therapy for fever in cancer patients with granulocytopenia

S ummary In a prospective randomized study, 100 episodes of fever (>38°C) and granulocytopenia (<1000/μ1) in cancer patients were empirically treated with ceftazidime (2 g every 8 h) plus teicoplanin (400 mg every 8 h on day 1: 400 mg every day thereafter) or ceftazidime (2 g every 8 h) plus amikacin (500 mg every 8 h).
Bacteraemia. clinically documented infection and possible infection were documented in seven. 11 and 19 patients treated with ceftazidime plus teicoplanin and in 11, four and 17 patients treated with ceftazidime plus amikacin. Overall, the response rate was similar in the two groups of patients as was the need for treatment modifications and the rate of death.
For documented Gram-positive bacteraemia, the response rate was 2/5 patients treated with ceftazidime plus teicoplanin and 2/7 with ceftazidime plus amikacin: for documented Gram-negative bacteraemia. the response rate was 1/2 and 3/4 patients respectively. No breakthrough bacteraemia was observed. Tolerance was excellent. although renal toxicity (elevation of serum creatinine) was observed in three patients treated with ceftazidime plus teicoplanin and in none allocated to ceftazidime plus amikacin.