No abstract

Trends in causative organisms and sources of infection were studied in a series of 288 episodes of bacteremia in neutropenic cancer patients observed in a single institution from 1986 to 1993. The incidence of bacteremia increased significantly from 20 episodes per 1000 admissions in 1986 to 50 episodes per 1000 admissions in 1993 (p = 0.00001). Over the study period, a continuous increment in gram-positive bacteremia, which reached 81% of episodes in 1993 (p = 0.000001), was observed. Conversely, the incidence of gram-negative bacteremia remained stable. Coagulase-negative staphylococci and viridans group streptococci were the most commonly isolated pathogens. Bacteremia caused by coagulase-negative staphylococci increased from 3 episodes per 1000 admissions to 19 episodes per 1000 admissions (p = 0.0001), and viridans group streptococci bacteremia increased from 0 episodes per 1000 admissions to 19 episodes per 1000 admissions (p = 0.000001). The upward trend in gram-positive bacteremia appeared to be related to a significant increase in both intravascular catheters (p = 0.003) and oral mucositis (p = 0.003) as sources of infection. Specific strategies to prevent chemotherapy-induced mucositis and catheter-related bacteremia merit further investigations.

The purpose of this study was to identify risk factors for mortality in neutropenic patients with cancer and bacteremia. A consecutive sample of 438 neutropenic patients (granulocyte count <0.5 x 10(9)/l) with cancer and bacteremia was studied to identify the clinical characteristics associated with mortality at the onset of bacteremia. The mean age of the subjects was 48 years (range, 15-87 years). Most cases of bacteremia (77%) were hospital-acquired and occurred in patients with acute leukemia (48%). Gram-positive organisms caused 233 (53%) episodes of bacteremia, gram-negative organisms caused 151 (34%) episodes, and 48 (11%) episodes were polymicrobial. The overall mortality within 30 days of the onset of bacteremia was 24.4%. The variables found to be independently associated with increased mortality using logistic regression techniques were as follows: shock at the onset of bacteremia (OR, 10; 95% CI, 4.2-23.8), pneumonia (OR,4.4; 95% CI, 1.9-10), uncontrolled cancer (OR,4.3; 95% CI, 1.5-12.7), and absence of prophylaxis with norfloxacin (OR,2.4; 95% CI, 1.3-4.5). The prognostic factors ascertained in this study may help to identify those patients at higher risk of death. Medical intervention addressing some of these factors may improve the outcome of bacteremia in neutropenic patients with cancer.

Damage of skeletal muscle in association with graft-versus-host disease (GvHD) has been referenced exceptionally. Eighteen months after bone marrow transplantation, a 22-year-old man developed polymyositis associated with manifestations of chronic GvHD, such as peripheral eosinophilia and localized morphea. Diagnosis of polymyositis was established by clinical, electromyographic, and histopathologic findings. His clinical condition improved with immunosuppressive therapy. At electronmicroscopy, some close and broad contacts between lymphocytes with activated appearance and degenerated muscle fibers were observed, suggesting a lymphocytotoxic mechanism. The findings support the idea that polymyositis can be considered a manifestation of chronic GvHD.

Summary:Intensive therapy followed by hematopoietic progenitor TNF-␣ (Tumor necrosis factor-alpha) is involved in administration has improved the prognosis of many dismany immunological and inflammatory processes, and eases in the last 30 years. However, this procedure is commight be expected to play an important role in the plicated by secondary events which may endanger the development of BMT-related complications. Triple therpatient's life in 23-35% of cases. 1 Conditioning-related apy (pentoxifylline, ciprofloxacin and prednisone) with toxicity, graft rejection, graft-versus-host disease and postknown anti-TNF activity was tested in 37 patients undergoing a hematopoietic progenitor transplant transplant immunodeficient status are the most frequent (HPT). A control group of 16 patients with similar complications after hematopoietic progenitor transplancharacteristics was selected among consecutive patients tation (HPT). receiving a HTP in a neighboring center who did not Basal disease, the source of hematopoietic progenitors receive anti-TNF prophylaxis. Major transplant-related and conditioning therapy used also influence patients' outcomplications were registered (VOD, acute GVHD, come. infectious episodes, renal failure and mucositis) and sur-TNF-␣ and other inflammatory cytokines have directly vival status. TNF plasma concentrations were deterbeen involved in tissue damage after HPT. 2 High TNF-␣ mined by ELISA, and pentoxifylline plasma concenlevels have been detected in patients with infectious epitrations were determined by HPLC. Among patients sodes, graft-versus-host disease (GVHD) and hepatic venotreated with pentoxifylline (PTX), ciprofloxacin and occlusive disease (VOD). 3,4 As TNF-␣ is thought to be steroids, no difference in the mean survival time was responsible for the initiation and perpetuation of tissue observed compared with the control group. The incidamage, strategies such as anti-TNF antibody adminisdence of procedure-related death up to day +35 was tration 5 or inhibition of TNF synthesis have been assessed 11% in the study group and 6% in the control group.in order to decrease transplant-related complications. In spite of a tendency to a lower incidence of mucositis Pentoxifylline (PTX) is a xanthine with a strong inhibithere was a higher incidence of infections (positive blood tory effect on TNF synthesis in vitro, 6 which may also procultures) in the study group (49%) than in the control tect experimental animals from renal dysfunction induced group (16.7%) (P = 0.16). This difference achieved statby cyclosporin A or amphotericin B. 7,8 istical significance in patients receiving an allogeneic Bianco et al 9 showed a decreased incidence of VOD, HPT (P = 0.05). It is likely that the use of steroids in the GVHD, mucositis, renal failure and fever in patients early period after transplant increases infectious epiundergoing BMT treated with PTX orally. Later reports sodes and makes control of GVHD difficult. The com-have not proven such a benefit. 10,11 bined administration of steroids w...