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Background: The use of combinations of antibiotics has been the cornerstone of therapy for febrile patients with cancer and severe neutropenia. Each empirical regimen should be selected according to the epidemiology and susceptibility patterns in each center. We describe here the experience with empirical antimicrobial treatments in pediatric patients with cancer, fever and severe neutropenia, and identify the risk factors associated with treatment failure., Methods: This is a prospective study including 145 patients with cancer, and 171 episodes of neutropenia and fever. Blood cultures were taken before initiating empirical treatment: a) carbenicillin (400 mg/kg/day) plus amikacin (21 mg/kg/day) (Cb/ak), and b) ceftazidime (100 mg/kg/day), plus amikacin at the same dosage (Cz/ak)., Results: The overall response rate was 54.9% and 56.3% for Cb/ak and Cz/ak, respectively. Fifty-seven episodes (33.3%) were microbiologically documented, gram-positive isolated in 38% and gram-negative in 49%. Risk factors associated significantly with treatment failure were acute myelocytic leukemia (AML) (RR 2.59, CI 95% 1.42-4.7, p = 0.003); bacteriological identification (RR = 4.41, CI 95% 2.21-8.8, p < 0.001), and the presence of two or more sites of infection (RR = 2.89, CI 95% 1.03-8.11, p = 0.03)., Conclusions: The rates of response are similar to the combinations used in the hospital (Cb/ak, Cz/ak). The risk factors associated with treatment failure were AML diagnosis, bacteriological identification, and the presence of two or more sites of infection.

A randomized clinical trial was performed in children with cancer, fever and neutropenia, to evaluate the efficacy of amikacin once daily versus thrice daily dosing plus carbenicillin in both groups. Fifty patients were included, 25 patients in group A who received amikacin once daily and 25 in group B who received amikacin thrice daily. No intergroup differences were observed, i.e., fever diminished in a median of 6 days (2-8 days) vs. 7 days (3-12 days) in groups A and B respectively (p = 0.37);clinical improvement was observed in a median of 6 days (3-10 days) vs 7 days (2-14 days) (p = 0.68). One patient in group A and two in B died. The peak levels of amikacin on the 7th day of treatment were 10-60 and 7-25 micrograms/mL in groups A and B respectively, and the serum creatinine levels were 0.3 - 0.7 for group A and 0.2 - 0.8 mg/dL for group B; none of the patients presented a creatinine above 40% of the basal value. Three patients of group A had amikacin levels higher than 40 micrograms/mL without increasing the creatinine levels; our observations do not suggest that toxicity is higher. We conclude that the administration of aminoglycoside once daily seems to be as effective as the traditional dosing.

Aim: Children with leukaemia are at increased risk of pulmonary complications, often with unspecific clinical data, delayed diagnosis and a high mortality rate. We evaluated the usefulness of diagnostic–therapeutic guidelines (DTG) in which specific times for decision making were incorporated. Methods: Clinical charts of children with acute leukaemia and suspicion of pulmonary involvement were reviewed. Patients were allocated to group I if their diagnostic and therapeutic decisions were in accordance with the DTG, and to group II if not. Results: Children from group I (n = 32) and group II (n = 28) did not differ with respect to age (9.3 ± 0.5 years old, mean ± SEM), gender, type, risk and stage of leukaemia, anaemia and neutropenia. Total length of hospital stay and hospitalization due to the pulmonary disease were shorter in group I than in group II (14.8 ± 2.1 vs. 28.5 ± 3.7 days, p = 0.0016; and 10.8 ± 1.0 vs. 18.4±1.8 days, p = 0.0003, respectively). Two patients (6.3%) died due to the pulmonary pathology in group I, and nine (32.1%, p = 0.016) in group II. Conclusions: Diagnostic–therapeutic guidelines that incorporate timely decisions constitute a useful algorithm to reduce the length of hospital stay and mortality in children with acute leukaemia and pulmonary infiltrates. A prospective study is needed to validate these results. [ABSTRACT FROM AUTHOR]