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The optimal management of fever in granulocytopenic patients remains controversial. This pilot study investigated the potential value of single daily doses of amikacin administered empirically with ceftriaxone in febrile granulocytopenic patients. None of the patients died as a result of infection or toxicity from the prescribed regimen. Serum concentrations failed to show drug accumulation. Modifications of empirical antimicrobial therapy were made at a similar rate to other conventional regimens. Vancomycin seemed to increase the incidence of nephrotoxicity. Overall, this pilot study suggests that empirical therapy with single daily doses of amikacin plus ceftriaxone is safe and effective and should be further investigated in a larger number of patients.

Seventy-four immunocompromised patients with severe infection due to gram-positive organisms were randomized to receive either vancomycin or teicoplanin. Extensive cancer was present in 71 patients, of whom 47 died within a month. The types of infections were 46 bacteremias (39 associated with central catheters), 24 skin and soft tissue infections (3 with bacteremia), and 7 others (mainly bronchopneumonia). The most frequent pathogen was Staphylococcus epidermidis, followed by Staphylococcus aureus. Microbiological eradication was obtained in 23 of 35 evaluable patients treated with vancomycin (65.7%) and 28 of 36 patients treated with teicoplanin (77.8%) (P = 0.4). Clinical cure and improvement were obtained in 26 of 35 patients (74.3%) and 27 of 36 patients (75.0%), respectively. No significant side effects were observed with teicoplanin, in contrast to reversible increases in serum creatinine (three patients) and skin rashes (four patients) with vancomycin. Superinfection was observed in five patients treated with vancomycin and two patients treated with teicoplanin. No relation was found between peak concentration in serum (at steady state) or bactericidal titers and outcome.

Bacterial peritonitis is a common complication associated with catheters implanted for intraperitoneal anticancer chemotherapy in patients with extensive ovarian carcinoma. During an ongoing trial of intraperitoneal cisplatin-melphalan vs. cisplatin-gamma interferon, given via an intraperitoneal 'Port-a-cath' catheter, 6 episodes of suspected bacterial peritonitis occurred in 5 patients. Clinical symptoms were present in all episodes and 3 episodes were documented microbiologically. Teicoplanin was given intraperitoneally, 400 mg three times a day on the first day and once daily thereafter. Serum and peritoneal concentrations were measured by bioassay. Despite clinical improvement during therapy, the catheter was removed in 4 out of 5 patients after the end of intraperitoneal teicoplanin, due to the presence of infection. Additional patients are required to evaluate the efficacy of intraperitoneal teicoplanin in the treatment of catheter-related peritonitis associated with anticancer intraperitoneal chemotherapy.

Gram-positive pathogens have become a common cause of bacteraemia in granulocytopenic cancer patients. This has been partially attributed to the use of central intravenous devices such as Hickman catheters; mucositis secondary to intensive antineoplastic chemotherapy or herpes infections may also be the source, especially for streptococci, whereas the skin is most probably the source for Staphylococcus epidermidis. Antimicrobial prophylaxis recommended mainly with the aim of reducing the incidence of Gram-negative bacillary infections may also play a significant role. The rate of response of documented infections caused by Gram-positive cocci to 'standard' empirical therapy (which has been mainly directed against Gram-negative bacilli) has been unsatisfactory although the lethality reported has been low. These results raise an important question, whether or not a specific anti-Gram-positive antibiotic such as vancomycin, should be added to the empirical regimen. A recent study suggested that empirical vancomycin provided no benefit since the mortality due to Gram-positive infections was low and a favourable outcome was obtained by adding a specific antibiotic after bacteriological documentation. However, others have shown that empirical use of vancomycin was associated with a more rapid resolution of fever. Vancomycin has been associated with an excess rate of side-effects and is difficult to administer. Another important question is whether or not antimicrobial prophylaxis for gut decontamination should include anti-Gram-positive cover. Recent studies have confirmed that Gram-negative bacillary bacteraemia may be prevented by oral gut decontamination but not bacteraemia due to Gram-positive bacteria.(ABSTRACT TRUNCATED AT 250 WORDS)

One hundred twenty-nine 111In-oxine-labeled leukocyte scintiscans have been performed in 117 patients with cancer in order to diagnose localized infectious disease. Of the 115 contributive scans, 40 were in patients with localizing signs, whereas in 75 fever of unknown origin constituted the indication for this examination. The overall specificity of the method was 95.4%, the overall sensitivity 86%, and the global accuracy 91.3%. In 10 cases with localizing signs, the 111In-oxine granulocyte scintigram allowed exclusion of the diagnosis of infection, whereas in 17 instances without localizing signs, a focal infectious process was demonstrated. Heterologous donor leukocytes were used successfully in five instances. With the exception of accumulation of label at the site of an osteolytic metastasis in one case, no uptake was observed in primary or secondary tumors. It is concluded that 111In-oxine-labeled leukocytes constitute a valuable tool in the diagnosis and localization of infection in patients with malignant disease.

Twenty-four patients were treated with moxalactam for 25 serious infections. Nineteen patients were septicemic and 18 presented severe underlying diseases considered to impair the normal response to bacterial pathogens. All of the pathogens had MICs of less than 12 mg/l except one Pseudomonas aeruginosa strain with an MIC of 32 mg/l. The dosage ranged from 3 to 12 g/day; the route of administration was either i.v. or i.m. The duration of treatment was six to 26 days. Six patients had urinary tract infections (three bacteremia), four had pulmonary abscesses (two bacteremia), five had septic thrombophlebitis (five bacteremia) and ten had miscellaneous infections (nine bacteremia). Twenty-two (92%) patients responded favourably. Four patients (16.6%) developed superinfections due to organisms highly resistant to moxalactam: three Streptococcus faecalis, one Bacteroides fragilis and one Aspergillus flavus. Tolerance was good. Nine moderate adverse reactions were observed: three cases of transient eosinophilia, two of phlebitis, three hepatic enzyme alterations and one rash. Moxalactam kinetics were measured in serum from 15 patients with normal renal function after receiving 1 g i.v. over 30 min. The mean peak level after the infusion was 82.8 +/- 12.1 (SE) mg/l; the mean trough level 8 h later was 6.2 +/- 1.7 (SE) mg/l. The serum half-life was 2.6 +/- 0.6 (SE) h for the beta phase. Plasma clearance was 76.8 +/- 8.2 ml/min. Moxalactam was found to be highly effective in the therapy of life-threatening infections.

Teicoplanin was evaluated in 47 patients with severe infections, including 14 patients with bone infections, 11 patients with soft-tissue infections, 7 patients with endocarditis, 5 patients with pneumonia, 3 patients with septic thrombophlebitis, 3 patients with septicemia of unknown origin, and 4 patients with miscellaneous infections. Overall, bacteremia was documented in 24 patients. The pathogens isolated were 35 strains of Staphylococcus aureus (including 8 methicillin-resistant strains), 4 strains of Staphylococcus epidermidis, 4 strains of Streptococcus faecalis, 2 strains of Streptococcus pneumoniae, 5 strains of other streptococci, and 1 Micrococcus luteus strain. A total of 22 patients (46.8%) were clinically cured, 8 patients (17.0%) improved, 2 patients (4.3%) had relapses after initial improvement, and 15 patients (31.9%) failed to respond. The results were better in nonbacteremic patients (19 of 23 patients [82.6%] were cured or improved) than in patients with bacteremia (12 of 24 patients [50%] were cured or improved). Bacteriological cure occurred in 25 patients (53.2%), and superinfections were documented in 6 patients (12.8%). No major adverse effects were observed. We conclude that teicoplanin is a potentially effective and well-tolerated antimicrobial agent for therapy of nonbacteremic infections caused by gram-positive bacteria.

Seventy patients admitted for abdominal surgery requiring short-term perioperative prophylaxis were randomized to receive minocycline + gentamicin or metronidazole + gentamicin. Thirty patients were considered to be infected at the time of surgery and were treated with the same regimen. In the prophylactic cohort, one patient from each group developed postoperative fever. One patient receiving minocycline developed a wound infection. The overall infection rate was 2.6%. In the treatment cohort, it appeared that the patients receiving metronidazole had more severe underlying diseases than those receiving minocycline. Consequently, more postoperative non-infectious complications were observed in the former. Minocycline + gentamicin appeared at least as effective than metronidazole + gentamicin in preventing postoperative infectious complications associated with abdominal surgery or in treating intra-abdominal infections.

In four adult women with various clinical conditions, curved anaerobic bacilli, similar to organisms recently assigned to the new genus Mobiluncus, were isolated from extragenital sources. None of the patients presented symptoms or clinical abnormalities related to the genital tract. The clinical data of these cases are reported and the microbiological findings are briefly described.

The practical procedures of digestive tract decontamination and prophylaxis of bacterial infection in granulocytopenic patients are debated. Fluoroquinolones are active against Gram-negative bacilli and have few side-effects. Pefloxacin was administered prophylactically to patients with cancer and granulocytopenia. None of them developed Gram-negative septicaemia, but 2 cases of streptococcal septicaemia were observed. The drug was well tolerated by all patients except one. Studies are currently in progress to try to reduce the incidence of septicaemia caused by Gram-positive cocci, using pefloxacin combined with penicillin.

Twenty patients with severe infections were treated with a fixed combination of ticarcillin + clavulanic acid. Nineteen of them had severe underlying diseases. Fifteen were bacteraemic; four of these were in shock. Eleven were infected with microorganisms resistant in vitro to ticarcillin. Eleven were clinically cured, 6 improved and 3 failed to respond, the latter being infected with ticarcillin-resistant microorganisms (2 E. coli, 1 P. mirabilis). Six patients experienced side-effects, which were usually mild and reversible, consisting mainly of moderate elevation of serum transaminases. In one patient ticarcillin-clavulanic acid was stopped due to worsening of a pre-existing drug hepatitis.