Positive Dialysate Gram Stain Predicts Outcome of Empirical Antibiotic Therapy for Peritoneal Dialysis-associated Peritonitis

Empirical antibiotic treatment with a first-generation cephalosporin plus gentamicin for peritoneal dialysis (PD)-associated peritonitis before culture results are available is still wildly used due to concerns regarding the economic burden and antibiotic-resistant bacterial infections. The aim of this study is to define the factors that predict the outcome of empirical antibiotic therapy for PD peritonitis. This is a retrospective study of patients with PD peritonitis over the last 10 years. Patients who had been treated empirically with intermittent intraperitoneal first-generation cephalosporin and gentamicin were enrolled. Eighty-three patients had 192 episodes of PD peritonitis. In total, 159 peritonitis episodes were treated with intraperitoneal antibiotics combined with first-generation cephalosporin and gentamicin empirically. Twenty-five peritonitis episodes had no pathogens identified by dialysate culture. In total, 122 (122/159, 76.7%) PD peritonitis episodes were caused by bacteria, 9 (9/159, 5.7%) were fungal, and 3 (3/159, 1.9%) were Mycobacterium tuberculosis peritonitis. Sixty-four (64/159, 40.3%) peritonitis episodes were successfully cured by empirical intraperitoneal antibiotic therapy. Empirical antibiotic treatment failed in 95 episodes (95/159, 59.7%). The positive rates of dialysate Gram stain in the empirical treatment success and failure groups were 15.6% and 40.0%, respectively (P = 0.001). The odds ratio of empirical treatment failure with a positive bacteria Gram stain was 3.60 (95% CI: 1.65–7.82). The dialysate Gram staining result was a significant predictor of empirical antibiotics treatment outcome for PD-associated peritonitis. Therefore, using an empirical antibiotic regimen for patients with an initial positive bacterial Gram stain of the dialysate should be introduced cautiously.     

Bronchoscopy guided by high-resolution computed tomography for the diagnosis of pulmonary infections in patients with hematologic malignancies and normal plain chest X-ray

BACKGROUND AND OBJECTIVES: High-resolution computed tomography (HRCT) of the chest is able to demonstrate the presence of pulmonary infiltrates in febrile neutropenic patients with normal chest X-rays. Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is a safe procedure for the etiological diagnosis of pulmonary infiltrates in oncohematologic patients. The objective of this study was to determine the diagnostic yield and subsequent therapeutic changes of a protected BAL (p-BAL) guided by HRCT in febrile oncohematologic patients unresponsive to broad-spectrum antibiotics with a normal chest X-ray. DESIGN AND METHODS: Twenty-two episodes from 20 oncohematologic patients were included: group A, 9 episodes (8 patients) with no respiratory symptoms and group B, 13 episodes (12 patients) with signs or symptoms of pulmonary infection. HRCT and p-BAL were performed in all episodes within the first 24 hours. RESULTS: HRCT showed abnormalities in all 22 episodes (bilateral abnormalities in 14 of the 22 episodes [64%]) and the most frequent pattern was ground-glass infiltrate (7 out of 22 episodes). An infectious agent was isolated in 12 of the 22 episodes, 5 in group A and 7 in group B with a diagnostic yield of 54%. Antimicrobial therapy was modified in 12 of the 22 episodes (54%): 5 in group A and 7 in group B. In 6 episodes, treatment was changed according to HRCT results and in the remaining 6 due to positive microbiologic results. Modifications in empirical therapy were associated with a favorable response in 44% episodes of group A and in 31% of group B. INTERPRETATION AND CONCLUSIONS: Oncohematologic patients with fever of unknown origin unresponsive to empirical antibiotics and with a normal chest X-ray can be candidates to undergo a HRCT. This subgroup of high-risk patients can benefit from a combined strategy consisting of BAL guided by a previous HRCT.     

Clinical characteristics and outcomes of patients with extended-spectrum ��-lactamase-producing bacteremias in the emergency department

Extended-spectrum β-lactamase (ESBL)-producing bacteria have been spreading from hospitals to communities. Despite this, there are limited emergency department (ED) patient-based studies about these bacteremias. A retrospective matched case-control study with a ratio of 1:3 was conducted at a university hospital. The case group consisted of patients aged >16 years with ESBL-producing bacteremias in the ED. Patients matched for age and sex with non-ESBL-producing bacteremias were sampled as the control group. Finally, 64 episodes of ESBL-producing Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis bacteremias were included in our study. The median age of case patients was 71 years, and 29 (45.3%) were males. The most common type of infection was urinary tract infection (71.9%), followed by intra-abdominal infection (12.5%). Inappropriate empirical antibiotics therapy was prescribed in 87.5% of case patients, which was significantly higher than the control group (13.0%; p < 0.001). Patients with inappropriate empirical antibiotics had a significantly longer hospital stay than those with appropriate empirical antibiotics (p < 0.001). Multivariate analysis showed that hospital-acquired infection, urinary catheterization, and previous antibiotics use were independent risk factors for the acquisition of ESBL-producing bacteremia. The 28-day mortality rate of case patients was 18.8%. Whether they received appropriate empirical antibiotics treatment or not, there was no statistical difference in the mortality of patients with ESBL-producing bacteremias (p = 0.167). To face these emerging multidrug-resistant bacteria and to guide the empirical antibiotics therapy, it is crucial for emergency physicians to recognize the characteristics and risk factors for ESBL-producing organisms.     

Oral ciprofloxacin plus colistin: prophylaxis against bacterial infection in neutropenic patients. A strategy for the prevention of emergence of antimicrobial resistance

Following a 2-year study, the combination of oral ciprofloxacin and colistin has been used continuously for 10 years without the emergence of resistance. During a 2-year period (1987-1989), we compared ciprofloxacin + colistin (CIP + COL) with neomycin + colistin (NEO + COL) in a randomized trial--combinations chosen because of the potential for prophylaxis of Gram-negative infection by ciprofloxacin, with colistin given to reduce the risk of emergence of resistance. Sixty-four patients with similar demographics in each arm were evaluable for efficacy analysis. Patients on CIP + COL had a significantly lower proportion of neutropenic days with fever (P < 0.001) and neutropenic days on intravenous antibiotics (P < 0.001) than patients on NEO + COL. A total of 54 (15 bacteriologically documented) pyrexial episodes occurred in patients on CIP + COL and 77 (41 bacteriologically documented) in patients on NEO + COL. Only two Gram-negative bacterial infections occurred in the CIP + COL arm compared with 16 in the NEO + COL arm. No Staphylococcus aureus infections occurred in the CIP + COL group compared with 10 in the other patients. Two CIP-resistant Gram-negative bacilli were isolated from patients on CIP + COL compared with 13 NEO-resistant Gram-negative bacilli from patients on NEO + COL. Following a subsequent decade of unchanged use of this prophylactic strategy in neutropenic patients, a 2-year follow-up study between 1 January 1998 and 31 December 1999 showed 66 significant infections during 700 [corrected] neutropenic episodes. Thirty-five of the 111 (31%) isolates were ciprofloxacin-resistant, involving 5% of the neutropenic episodes [corrected].     

Cefotaxime, desacetyl-cefotaxime, and bactericidal activity in spontaneous bacterial peritonitis.

We have prospectively studied 13 episodes of spontaneous bacterial peritonitis (SBP) in 12 patients treated with cefotaxime (CTX) 2 g intravenously every 8 h (mean duration, 5.3 days). Ascitic fluid was inoculated at the bedside. The cultures were done before, during (day 3 after CTX initiation), and 48-72 h (mean, 56 h) after the end of therapy. All SBP episodes were monomicrobial. During treatment, the concentrations of CTX and desacetyl-cefotaxime (d-CTX) in ascitic fluid were high in all 13 SBP episodes, and d-CTX was still present in 6 patients who had residual ascitic bactericidal titer (ABT) activity after the last dose of CTX. ABTs were >/=1:128 during CTX therapy in 12 episodes and were measurable in 7 patients after the last dose. All patients were cured. The present study provides scientific rationale to the clinical studies that suggest treating SBP episodes with lower doses of antibiotics and shorter treatment duration.     

A comparison of imipenem to ceftazidime with or without amikacin as empiric therapy in febrile neutropenic patients.

BACKGROUND--Neutropenic patients with cancer are traditionally treated with empiric antibiotic combinations when they become febrile. The availability of broad-spectrum antibiotics such as ceftazidime and imipenem has made it possible to initiate therapy with a single agent (monotherapy). The objectives of this trial were to compare ceftazidime and imipenem as single agents for the therapy of febrile episodes in neutropenic patients and to ascertain whether the addition of an aminoglycoside (amikacin) to either of these agents would provide an advantage. METHODS--A prospective clinical trial was conducted in which eligible neutropenic patients with cancer were randomized to one of four treatment arms: ceftazidime alone; imipenem alone; ceftazidime plus amikacin; and imipenem plus amikacin. Efficacy analysis was done for 750 assessable episodes. A multivariate logistic-regression analysis was also performed to examine the unique contribution of various prognostic factors. RESULTS--The overall response rates were 76% with imipenem plus amikacin, 72% with imipenem, 71% with ceftazidime plus amikacin, and 59% with ceftazidime alone. Single-organism gram-positive infections occurred in 101 of 750 episodes. Without a change in antibiotics, the response rates were 50% with imipenem, 40% with imipenem plus amikacin, 39% with ceftazidime plus amikacin, and 38% with ceftazidime. Most responded to vancomycin or other antibiotics, and the mortality associated with gram-positive infections was only 5%. Regardless of the antibiotic regimen, the majority of uncomplicated gram-negative infections responded to therapy and the majority of complicated gram-negative infections failed to respond. Multivariate logistic-regression analysis showed that recovery of the neutrophil count was the most favorable prognostic factor in a patient's response to infection, whereas the presence of gram-positive infection, acute leukemia, pulmonary or enteric infection, and therapy with ceftazidime were unfavorable factors. CONCLUSIONS--Single-agent therapy with imipenem is as effective as more conventional combination antibiotic therapy for the empirical treatment of febrile episodes in neutropenic patients with cancer.     

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.     

Empirical antibiotic therapy in febrile neutropenic patients with acute leukemia

One hundred and ninety-five episodes of fever during the neutropenic phase of chemotherapy in 49 patients with acute leukemia from 1984 to 1987 were analyzed with the following results: 1) Febrile episodes occurred in 80 percent of the neutropenic (less than 500/microliters) phase lasting more than 7 days after chemotherapy. 2) Febrile episodes consisted of 44 (22%) of established septicemia and 111 (57%) of suspected septicemia. 3) The pathogens causing septicemia were 8 GPC, 38 GNB (22 Pseudomonas species) and 6 fungi. Fungemia was confirmed on an average of 4.8 days after the onset of fever. The mortality of septic events was 10 out of 17 episodes (59%) when treated with antibiotics alone, while 8 out 27 (30%) with the combination of antibiotics plus antifungal drugs. 4) The mortality of suspected sepsis was only 2 out of 111 episodes. Eighty-three (75%) of these 111 episodes responded to antibiotics alone, while 26 (23%) cases needed antibiotics plus antifungal drugs. Our results suggest that in febrile neutropenic patient empiric broad-spectrum antibiotic therapy should be initiated which is especially effective for Pseudomonas species, but if fever persists despite more than 4 or 5 days of antibiotic therapy, additional antifungal therapy should be considered.     

Bacteremia caused by Enterobacter: 15 years of experience in a cancer hospital

A total of 296 episodes of bacteremia due to Enterobacter occurred in 281 patients with cancer between 1972 and 1986. The majority of these episodes were caused by Enterobacter cloacae. Seventy-four percent of the patients developed their infection while in the hospital and 55% had received therapeutic antibiotics during the 10 days preceding the onset of the infection. Enterobacter bacteremia was associated with shock in 24% of the patients and with disseminated intravascular coagulation in only 3%. The overall rate of response to therapy was 79% and increased to 85% during the last 5-year period. Only five patients remained afebrile during their infection, but four of these five died. Only 37% of the patients with shock responded to therapy compared with 93% of the patients without shock. The rate of response to therapy was 86% among patients without pulmonary infection compared with only 53% among those with pulmonary infection. The response rate to therapy with a single antibiotic was 73% and that to therapy with two antibiotics was 85%. As single therapeutic agents aminoglycosides were less effective than beta-lactam agents.     

Measurement of C-reactive protein in adults with febrile neutropenia after hematopoietic cell transplantation

The aim of this study was to evaluate the usefulness of C-reactive protein (CRP) monitoring in the differential diagnosis and prognosis of febrile neutropenic episodes in hematopoietic cell transplantation (HCT). In all, 100 patients were enrolled in the study. The CRP was determined in serum every 48 h from admission until resolution of the febrile episode. All patients presented with fever during the post-HCT neutropenic period. The febrile episodes were classified as microbiologically documented infection in 32 cases, clinically documented infection in 27 patients and fever of unknown origin in 41 patients. The mean CRP values on the first day of fever in these three groups were similar (NS). On the fifth day of antibiotic treatment, 50 patients remained pyrexial. Of these, 41 improved with modifications of antibiotherapy (mean CRP: 9.5 mg/dl; standard deviation (s.d.): 6.2) and nine died, five due to an infectious etiology (CRP: 21 mg/dl; s.d.: 4.4; P<0.003) and four from other causes (CRP: 11 mg/dl; s.d.: 3.4). On multivariate analysis, the CRP on the fifth day of treatment was an independent prognostic factor for fatal outcome. We conclude that persistent elevation of the CRP is an independent factor predicting a fatal outcome in patients who remain febrile on the fifth day of antibiotherapy during neutropenic febrile episodes post-HCT.     

Non-thyphoidal salmonellosis in patients with systemic lupus erythematosus. A study of fifty patients and a review of the literature

The objective of this study was to characterize the clinical profile of lupus patients with non-typhoidal salmonellosis. A retrospective review of the clinical charts of lupus patients diagnosed with bacteriologically proven non-typhoidal salmonellosis over the last 20 y was undertaken, paying special attention to risk factors, clinical presentation and treatment outcome. Most episodes were bacteraemic without a localizing focus; and some patients were afebrile. They usually occurred in patients prone to opportunistic infections, and at times of increased immunosuppression given for lupus flares (especially nephritis). However, salmonellosis also occurred in some patients presenting with lupus. The C-reactive protein level was found to be significantly higher during the infective episodes compared to episodes of non-infective febrile lupus flare. All isolates were sensitive to the usual first-line antibiotics and eminently treatable with 3 weeks of appropriate antibiotics without recurrence/persistence or significant morbidity/mortality, the exceptions being spinal osteomyelitis and septic arthritis involving deformed joints requiring surgical debridement and prolonged antibiotic therapy for eradication. Mortality occurred in the setting of septic shock from mixed-microbial sepsis and major organ failure from active lupus. There is a high association of non-epidemic, non-typhoidal salmonellosis with SLE, especially in patients with active disease on intensified immunosuppression. The C-reactive protein value may be helpful in distinguishing between fever from a pure lupus flare and one complicated by infection.     

Antibiotics and growth factors in the management of fever and neutropenia in cancer patients

The association of neutropenia and infection continues to be a major cause of morbidity and mortality in cancer patients receiving myelosuppressive chemotherapy. Prompt hospitalization and initiation of empirical intravenous broad-spectrum antibiotics has been the standard of care during the past three decades. Recently, risk-assessment models have been developed that allow the identification of febrile neutropenic patients that are at low risk for medical complications and mortality. New treatment strategies are being evaluated in this low-risk patient population to safely reduce toxicity, decrease costs, and improve quality of life. These include early shift from intravenous therapy to oral antibiotics, immediate initiation of oral empiric treatment, early hospital discharge, or outpatient care. A risk-based approach should also be applied to the use of colony-stimulating factors in this setting. Growth factors should not be routinely administered to neutropenic patients with uncomplicated febrile episodes. However, recent data support their use in populations with high-risk neutropenic fever.     

Antifungal therapy in patients with hematological malignancies: how to avoid overtreatment?

Historically, treatment of invasive fungal infections (IFI) has consisted of amphotericin B. However, new therapeutic agents have recently been introduced. At the same time, the relatively low incidence of IFI and the progress in the diagnostic accuracy of IFI have made routine use of empirical antifungal therapy questionable. OBJECTIVES AND METHODS: With the aim to define the present trends in the use of antifungal agents for the treatment of IFI, we prospectively observed type, safety, and efficacy of given antifungal treatment in patients with hematological malignancies during a recent 18-month period. We also analyzed the impact of restricted use of empirical antifungal therapy on IFI-related mortality. RESULTS: A total of 279 episodes of neutropenia and fever following the chemotherapy were recorded. Treatment of IFI was given during the management of 41 (14%) episodes. Voriconazole (27 episodes) and caspofungin (14 episodes) were the only antifungal agents used as initial therapy. The rate of antifungal therapy success outcome was 78%. The overall 4-week mortality rate was 8%. Two patients died of invasive pulmonary aspergillosis. Empirical antifungal therapy was given in 13 episodes with persistent febrile neutropenia (PFN) and resulted in successful outcome in 92% of cases. In general, antifungal agents were well tolerated and only two patients had to discontinue treatment because of severe adverse event. In 127 episodes of PFN, antifungal therapy was deemed unnecessary and accordingly was not administered. In this subgroup of patients, no IFI-related mortality occurred. CONCLUSION: A better tolerability and efficacy of voriconazole and caspofungin together with the availability of an oral formulation of voriconazole most probably contributed to the observed shift in the use of antifungal agents. A restricted use of empirical antifungal therapy was, in this setting, not associated with an increased IFI-related mortality.     

Short Courses of Intravenous Empirical Antibiotic Treatment in Selected Febrile Neutropenic Children with Cancer

Background: Since the optimal duration of antibiotic therapy in febrile neutropenic patients is not clear, we evaluated the safety and efficacy of short courses of intravenous antibiotic treatment in selected pediatric cancer patients admitted for fever and neutropenia. Patients and Methods: We retrospectively analyzed the clinical course of children with chemotherapy-induced neutropenia and fever. All patients were treated with empirical intravenous antibiotics. In episodes of fever of unknown origin (FUO), treatment regimen allowed discontinuation of antibiotics and early hospital discharge regardless of absolute neutrophil count (ANC) or evidence of bone marrow recovery as long as patients were afebrile for at least 24 h and had been treated for a minimum of 72 h. Results: 106 episodes of febrile neutropenia occurred in 56 patients. 84 episodes were classified as FUO and intravenous antibiotic therapy was discontinued regardless of ANC when patients met the criteria described above. No death or major complication occurred. None of the patients had to be rehospitalized for recurrent fever or infection. Conclusion: Discontinuation of intravenous antibiotics regardless of ANC or evidence of bone marrow recovery seems safe and effective in pediatric cancer patients with FUO when children are afebrile for at least 24 h and are treated for a minimum of 72 h. Received: June 28, 2001 · Revision accepted: October 29, 2001     

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.     

Outcome of bacteremia and fungemia in paediatric oncology patients

OBJECTIVE:

To determine the outcome of paediatric oncology patients with positive blood cultures.

DESIGN:

Retrospective chart review.

SETTING:

Tertiary care hospital.

POPULATION STUDIED:

Oncology patients up to 17 years of age with positive blood cultures from January 1, 1994 to March 31, 1999.

MAIN RESULTS:

There were 121 episodes of positive blood cultures in 76 patients. Seventeen episodes were excluded because blood cultures were contaminated. Of the organisms grown from the remaining episodes, 63% were Gram-positive organisms, 23% were Gram-negative organisms, 3% were fungal and 11% were mixed. There were 13 episodes with pure or mixed isolates of Staphylococcus aureus, of which nine occurred within 14 days of the placement of a new central venous tunnelled catheter. Central venous tunnelled catheters were retained in 76 of the 102 episodes when they were present. There were two relapses, and four children were admitted to the intensive care unit with septic shock, but all survived.

CONCLUSIONS:

The outcome was excellent with the current management of possible bacteremia in paediatric oncology patients, but the high incidence of S aureus bacteremia suggests that empirical antibiotics should be altered if sepsis is suspected within 14 days of the placement of a central venous catheter.Key Words: Bacteremia, Empirical antibiotics, Fungemia, Oncology, PaediatricBacteremia and fungemia are common causes of morbidity in paediatric oncology patients. Mucositis of the gastrointestinal tract undoubtedly results in increased opportunities for bacteremia to occur. Impaired host defenses and the seeding of indwelling venous lines increase the chance that this bacteremia will be continuous rather than transient. Bacteremia also occurs following breaks in sterile technique during the manipulation of venous lines. The pathogenesis of fungemia in this patient population is not well delineated, but one likely source is from venous catheters being infected following transient fungemia from gut flora.It is standard practice to start empirical antibiotics in all febrile oncology patients who are neutropenic. The empirical antibiotic regimen used in paediatric oncology patients in our centre is tobramycin and piperacillin. Most non- neutropenic febrile oncology patients are also admitted and started on these same antibiotics, because there is evidence that their incidence of bacteremia may be at least as frequent as that of neutropenic patients (1). In our centre, venous catheters are removed in the face of suspected line infection only if the venous catheters are nontunnelled, permanent venous access is no longer required, the infecting organism is a yeast, bacteremia persists after several days of appropriate antibiotics or the patient has septic shock that is thought to be line-related. The purpose of the present study was to evaluate the outcome of patients by using this approach to suspected bacteremia or fungemia.     

Early implementation of antifungal therapy in the management of febrile neutropenia is associated with favourable outcome during induction chemotherapy for acute leukaemias

Background: Mortality related to induction chemotherapy during the treatment of acute leukaemias (AL) has been estimated at 5–20%, and this increases with age. Fungal infection remains one of the major causes of morbidity and mortality and is considered an obstacle to the successful management of acute leukaemias. Methods: We retrospectively analysed all patients treated for acute leukaemias at a single institution between July 2006 and January 2009, to assess the impact of early antifungal therapy on outcome during induction chemotherapy. There were 44 episodes of induction chemotherapy, with a median age of patients of 61 years (range 18–81), including 29 patients with acute myeloid leukaemia, 9 with acute lymphoblastic leukaemia and 6 with relapsed AL. The median age was 61 years (range 18–81), and 20 patients were over the age of 60 years. Results: All patients who developed febrile neutropenia received broad‐spectrum antibiotics. Early empirical antifungal treatment was commenced with voriconazole (15 patients) or caspofungin (12 patients) if the febrile neutropenia did not resolve after 72 h of antibiotic therapy, in conjunction with radiological changes consistent with possible fungal infection. None of the patients succumbed during induction chemotherapy. The 120‐day mortality rate after the induction therapy was 2.2%, without any incidence of invasive fungal disease. Conclusion: Our analysis shows that early empirical treatment for fungal infection with voriconazole or caspofungin is associated with a favourable outcome of induction therapy for acute leukaemias. Further studies to confirm this finding are warranted.     

C-reactive protein levels in neutropenic patients with pyrexia

This study describes the experience of a clinical haematology unit in dealing with pyrexial episodes in 62 patients. Serum C-reactive protein levels were serially estimated and proved to be useful in following the course of the illness. No significant difference could be demonstrated in the C-reactive protein levels of those patients with bacteriologically proven illnesses, those in whom a clinically evident infection was present, and those with a 'pyrexia of unknown origin'. However, those patients in whom disease activity was thought to be responsible for the pyrexia had significantly lower C-reactive protein levels compared with those patients who had a septicaemic illness.     

Efficacy of intravenous vancomycin in the treatment of gram-positive peritonitis in long-term peritoneal dialysis

Peritonitis is the major complication of long-term peritoneal dialysis. Gram-positive bacteria are responsible for two thirds of the total number of peritonitis episodes. Conventional therapy consists of daily administration of antibiotics, either parenterally or intraperitoneally. Vancomycin, an antibiotic with a prolonged half-life in renal failure, has a wide spectrum of activity against gram-positive bacteria and diffuses readily across the peritoneal membrane. In the present study, 82 percent of gram-positive peritonitis episodes were cured following the intravenous administration of vancomycin at weekly intervals. This cure rate compares favorably with that obtained following conventional therapy of peritonitis. It is concluded that intravenous vancomycin is an effective treatment for gram-positive peritonitis in patients undergoing long-term peritoneal dialysis. This form of therapy is convenient, reduces hospitalization, minimizes cost, and avoids possible contamination of the peritoneal dialysate used during the intraperitoneal administration of antibiotics.     

Low Rate of Clinical Consequences Derived from Results of Blood Cultures Obtained in an Internal Medicine Emergency Department

Abstract Background: Blood cultures detect bacteremia in individual patients and help define local pathogen and resistance spectra. At the same time, the benefits of blood culture results in the management of individual patients – and therefore their cost–effectiveness – are disputed. Patients and Methods: During 1 calendar year, we conducted a prospective study of emergency department admissions with blood culture draws and at least a 3–day hospitalization afterwards. We prospectively surveyed treating physicians on usefulness of blood culture results for patient management. Results: 428 diagnostic episodes (emergency visits) involving 390 patients occurred during the study period from 10/2002 to 10/2003. The analysis included 188/428 (44%) episodes with blood culture draws performed according to the predefined clinical standard where patients were hospitalized with sufficient duration. Absence of therapeutic consequences in response to blood culture results was reported for 138/142 (97%) of episodes with negative blood culture results, for 16/21 (76%) with blood culture results positive only for skin flora, and for 14/25 (56%) of episodes with blood cultures positive for obligate pathogens. Treating physicians regarded the blood culture results necessary for clarifying the etiology in 34/188 (18%) episodes, and rated blood culture results necessary for their therapeutic decisions in 29/188 (15%) episodes. Conclusion: Negative blood culture results rarely changed the management of medical inpatients. Our study suggests that in settings with broad–spectrum empirical antibiotic therapy positive blood culture results for obligate pathogens trigger adjustment of the antibiotic therapy in only about half of instances. Many blood cultures drawn in the emergency department where considered unnecessary by ward physicians. Guidelines for preventing unnecessary blood culture draws are warranted in order to increase the rate of their meaningful clinical consequences for medical inpatients initially treated with broad–spectrum empirical antibiotics. This paper is dedicated to the founders of the Walter Marget Foundation, D. Adam and F. Daschner, in gratitude for their support of the training in infectious diseases.