Patients with lymphoid cancer receiving ibrutinib treatment are at risk for serious infections, including IFIs.

Objectives To determine the prevalence, risk factors, treatments, and outcomes of bloodstream infections (BSIs) due to carbapenem-resistant Enterobacteriaceae (CRE) in adult neutropenic patients with hematologic malignancies. Methods We reviewed all BSIs between 2008–2012 in this population at two New York City oncology centers. A case-control study was conducted to identify CRE BSI risk factors, using three controls of non-CRE BSIs per case. Results CRE caused 43 (2.2%) of 1,992 BSIs overall and 4.7% of Gram-negative bacteremias. Independent risk factors for CRE BSI were prior β-lactam/β-lactamase inhibitor (adjusted odds ratio [aOR] 3.2; P=0.03) or carbapenem (aOR 3.0; P=0.05) use, current trimethoprim-sulfamethoxazole (aOR 24; P=0.001) or glucocorticoid (aOR 5.4, P=0.004) use, and having a prior CRE culture (aOR 12; P=0.03). Patients with CRE bacteremia had a median of 52 hours from culture collection until receipt of active therapy. They had a 51% BSI-related mortality rate, with a median of 4 days from bacteremia onset until death. CRE-active empirical therapy was associated with a lower 30-day mortality rate (17% vs. 59%; P=0.08). Conclusions CRE are lethal emerging causes of bacteremia in neutropenic patients. New strategies are needed to shorten the delay in administration of CRE-active agents and improve outcomes in this vulnerable population.

Prior studies have shown that delays in treatment are associated with increased mortality in patients with candidemia. The purpose of this study was to measure three separate time periods comprising the diagnosis and treatment of candidemia and to determine which one(s) is associated with hospital mortality. Patients with blood cultures positive for Candida spp. were identified. Subjects were excluded if no antifungal therapy was given or if there was preexisting antifungal therapy. Collected data included the time from blood culture collection to positivity (incubation period), the time from blood culture positivity to provider notification (provider notification period), and the time from provider notification to the first dose of antifungal given (antifungal initiation period). These times were assessed as predictors of inpatient mortality. A repeat analysis was done with adjustments for age, sex, race, underlying cancer, catheter removal, APACHE III score, acute renal failure, neutropenia, and non-Candida albicans species. A total of 106 episodes of candidemia were analyzed. The median incubation time was 32.1 h and was associated with mortality (univariate hazard ratio per hour, 1.025; P ‫؍‬ 0.001). The median provider notification and antifungal initiation periods were 0.3 and 7.5 h, respectively, and were not associated with mortality. Adjusted analysis yielded similar results. For cancer patients with candidemia, the incubation period accounts for a significant amount of time, compared with the provider notification and antifungal initiation times, and is associated with in-hospital mortality. Strategies to shorten the incubation time, such as utilizing rapid molecularly based diagnostic methods, may help reduce in-hospital mortality.

Meaningful reductions in SSI can be achieved by implementing a multidisciplinary care bundle at a hospital-wide level.

Recent surveillance from US hospitals shows that more than 99.5% of vancomycin-resistant enterococci (VRE) isolates remain susceptible to daptomycin. This report describes emergence of daptomycin-resistant VRE at a major cancer center. The percentage of patients with daptomycinresistant VRE bacteremia increased from 3.4% in 2007 to 15.2% in 2009 (P = .03). Without susceptibility data, empiric daptomycin therapy for VRE infections should be used with caution.Vancomycin-resistant enterococci (VRE) were first isolated in the United States in the late 1980s and have spread widely in the ensuing years. The most recent National Nosocomial Infection Surveillance (NNIS) report showed that 28.5% of all enterococcal isolates are resistant to vancomycin. 1 Studies have shown poorer clinical outcomes among patients with VRE infections when compared with those infected with vancomycin-susceptible enterococci. 2 In the past decade, 4 new drugs with activity against VRE have been licensed for use: quinupristin-dalfopristin (1999), linezolid (2000), tigecycline (2005), and daptomycin (2003). Few studies have examined and compared the efficacy of these agents for use in the treatment of VRE infections. Among the newer drugs, common adverse effects such as myelotoxicity (linezolid) and myalgias (quinupristin-dalfopristin) limit the use in certain circumstances, especially among patients undergoing treatment for cancer.Recent surveillance studies from US hospitals have demonstrated that more than 99.5% of VRE isolates remain susceptible to daptomycin. 3 The purpose of this report is to describe the recent emergence at our hospital of daptomycin-resistant VRE strains. METHODSWe examined the daptomycin susceptibility profile of all isolates collected during episodes of VRE bacteremia at Memorial Sloan-Kettering Cancer Center (MSKCC) from January (CDC), Atlanta, Georgia, using the broth microdilution method (cation-adjusted MuellerHinton broth). Pulsed-field gel electrophoresis (PFGE) was performed after SmaI digestion and interpreted according to criteria previously described. 5 Statistical analysisPoisson regression was used to perform time-trend analysis on VRE healthcare-associated infection (HAI) rates from 2005 through 2009. The proportion of isolates resistant to daptomycin was analyzed using the Cochran-Armitage test for linear trend. A P value ≤.05 was considered statistically significant. All analyses were performed using SAS, version 9.1 (SAS Institute). Of 18 patients with daptomycin-resistant VRE bacteremia, 15 (83%) had underlying hematologic malignancy (Table 1), 16 (89%) had no prior exposure to daptomycin, and 2 patients had received daptomycin for 5 and 17 days before the diagnostic culture sample was obtained. Of the 18 patients, 11 (61%) had mixed bacteremia, with isolation of daptomycinsusceptible and daptomycin-resistant strains during the same episode. Of these, only 1 had received daptomycin before or during the VRE bacteremia episode. RESULTS FromIsolates from 14 of the 18 patients with daptomycin-res...