Fungal endophthalmitis in a tertiary care cancer center: a review of 23 cases

Few data exist on the etiology, presentation, prognosis, and management of fungal endophthalmitis (FE) in cancer patients. FE cases were identified by reviewing the ophthalmology reports and microbiology cultures of patients at The University of Texas M. D. Anderson Cancer Center. We retrospectively reviewed the medical records and obtained information related to malignancy, fungal infection and its management, visual outcome, and mortality. We compared FE caused by Candida spp. (CE) to FE caused by molds (ME). Of the 102 cancer patients with a fungal infection for whom an ophthalmology consult was requested, 23 met the criteria for definite (N = 6) or probable (N = 17) FE (8 with CE, 15 with ME). All of the patients with ME had hematologic malignancies, whereas half of the patients with CE had solid tumor (P = .008). Only patients with CE had a history of surgery within 30 days of FE diagnosis (38%, P = .03). Fungal pneumonia [17 (74%)] and disseminated infection [14, (61%)] were common. The most common presenting symptoms were decreased vision [16 (70%)] and ocular pain [14 (61%)]. All treated patients received systemic antifungals (combination therapy in 72% of the cases). Seven patients (30%) underwent vitrectomy. Only one patient received intraocular injection of amphotericin B along with systemic antifungals. Four-week mortality was high [13 (57%)], especially in ME (73%, P = .04). Among the eight surviving patients where visual acuity could be assessed, visual outcome improved or remained stable in five (63%). FE in cancer patients occurs in the setting of severe, frequently disseminated opportunistic mycoses, is caused predominantly by hyalohyphomycetes, and is a marker for high 4-week mortality.     

Serious complications of vascular catheter-relatedStaphylococcus aureus bacteremia in cancer patients

Over the period 1986 to 1989, 53 cancer patients were identified with catheter-relatedStaphylococcus aureus bacteremia at the University of Texas M.D. Anderson Cancer Center. Septic thrombosis was diagnosed in 12 (23 %) patients and was suspected in another 3 (6 %). Of the 12 patients, five developed deep-seated infections (septic emboli, endocarditis, meningitis, abscess), compared with 2 of the 38 other patients with no septic thrombosis (p<0.01). Fever persisted for more than three days after antibiotic initiation in 52 % of the patients with complications (septic thrombosis and/or deep-seated infections), compared with 19 % of those without complications (p<0.02). Of the three patients with complications who were treated for 14 days with intravenous antistaphylococcal antibiotics, two relapsed; in contrast, all of the nine patients with complications who were treated for more than 14 days (mean 4 weeks) were cured, and none relapsed (p<0.05). Of the nine patients with complications who were treated with a long course of therapy, only one required surgery. The possibility of septic thrombosis and/or deep-seated infections should be considered in all cancer patients with catheter-relatedStaphylococcus aureus bacteremia, and if present, the condition should be treated with appropriate intravenous antibiotics for at least four weeks.     

The significance of blood cultures positive for emerging saprophytic moulds in cancer patients

The significance of blood cultures positive for emerging saprophytic moulds (e.g., Scedosporium apiospermum, Scedosporium prolificans, Paecilomyces spp.) was evaluated in 30 cancer patients (1996-2002). Diagnostic criteria proposed previously for evaluation of aspergillaemia were used. Blood cultures positive for emerging saprophytic moulds represented 1% of all positive fungal cultures. One case of catheter-related fungaemia was excluded. The remaining 29 cases consisted of true (n = 5), probable (n = 1), indeterminate (n = 7) fungaemia, and contamination (n = 16). True fungaemia was seen only in leukaemia patients and allogeneic bone marrow transplant recipients. S. apiospermum and S. prolificans were the commonest causes of true fungaemia.     

Antimicrobial activity and durability of a novel antimicrobial-impregnated bladder catheter

The main objective of this study was to examine the antimicrobial activity and durability of a novel indwelling bladder catheter impregnated with minocycline and rifampin. Thirty antimicrobial-impregnated bladder catheters were inserted transurethrally in spinal cord-injured patients and removed, in six groups of five catheters each, at 3, 7, 10, 14, 17 or 21 days. Removed catheters had detectable zones of inhibition against two different clinical isolates of each of the 10 tested uropathogens (Escherichia coli, Pseudomonas aeruginosa, Proteus mirabilis, Klebsiella pneumoniae, Enterobacter cloacae, Citrobacter diversus, Enterococcus faecalis, Enterococcus faecium, Staphylococcus saprophyticus and Candida albicans) for greater than 14 days after catheter insertion. The residual zones of inhibition and levels of antimicrobial agents in removed catheters were both inversely related to the duration of catheter placement. Minocycline and rifampin were undetectable in serum and urine. These results support the ongoing efforts for examining the clinical efficacy of these experimental bladder catheters.     

Antibiotic susceptibility of staphylococcal isolates from patients with vascular catheter-related bacteremia: potential role of the combination of minocycline and rifampin

The antimicrobial susceptibility to ten antibiotics of 197 staphylococcal isolates recovered over a 10-year period from patients with vascular catheter-related bacteremia was examined. Isolated organisms induced methicillin-sensitive Staphylococcus aureus (95 isolates), methicillin-resistant S. aureus (42 isolates) and methicillin-resistant S. epidermidis (60 isolates). A microtiter assay was used to determine the MIC and MBC of individual antibiotics and to conduct time-kill studies of certain drug combinations. The activity of clidamycin, cefamandole and oxacillin was generally restricted to methicillin-sensitive organisms, whereas daptomycin, novobiocin, teicoplanin and vancomycin exhibited bactericidal activity against all tested staphylococcal species. Bacterial resistance to ciprofloxacin was detected among the more recent isolates of methicillin-resistant staphylococci. Minocycline and rifampin demonstrated bacteriostatic and bactericidal activity, respectively, against all groups of organisms. The interaction of rifampin with minocycline, vancomycin, or novobiocin was generally indifferent. The results of this study support the ongoing efforts for evaluation of the antimicrobial efficacy of vascular catheters coated with the combination of minocycline and rifampin.     

Antibiotic-impregnated catheters associated with significant decrease in nosocomial and multidrug-resistant bacteremias in critically ill patients

OBJECTIVE: To evaluate the impact of using central venous catheters (CVCs) impregnated with the combination of minocycline and rifampin on nosocomial bloodstream infections (BSIs), morbidity, and mortality in cancer patients in the ICU. DESIGN: Prospective surveillance study consisting of the following two time periods: September 1997 through August 1998 (ie, fiscal year [FY] 1998); and from September 1998 through August 1999 (ie, FY 1999). SETTING: ICUs of a tertiary care hospital in Houston, TX. PATIENTS: Cancer patients in the medical ICU (MICU) and surgical ICU (SICU). INTERVENTIONS: ICUs started using CVCs impregnated with the minocycline-rifampin combination at the beginning of FY 1999. Measurements and main results:The rates of nosocomial BSIs and other patients' characteristics were compared for the two study periods to determine the impact of using the impregnated catheters in the ICU. Patients' characteristics, including antibiotic use, were comparable for the two study periods in both the MICU and the SICU. The rate of nosocomial BSIs in the MICU unit decreased from 8.3 to 3.5 per 1,000 patient-days (p < 0.01), and decreased in the SICU from 4.8 to 1.3 per 1,000 patient-days (p < 0.01) in FY 1999. Nosocomial vancomycin-resistant enterococcus (VRE) bacteremia also decreased significantly (p = 0.004). Length of stay in the MICU and SICU significantly decreased in FY 1999 (p < 0.01 and p = 0.03, respectively). The duration of hospitalization decreased for MICU and SICU patients (p = 0.06 and p < 0.01, respectively). The rate of catheter-related infections decreased from 3.1 to 0.7 per 1,000 patient-days in FY 1999 (p = 0.02). The decrease in infections resulted in net savings of at least $1,450,000 for FY 1999. CONCLUSIONS: The use of antibiotic-impregnated CVCs in the MICU and SICU was associated with a significant decrease in nosocomial BSIs, including VRE bacteremia, catheter-related infections, and lengths of hospital and ICU stays.