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A chest infiltrate is needed to make a diagnosis of community-acquired pneumonia, but chest X-rays might be time consuming, entail radiation exposure, and demand resources that are not always available. We sought to derive a model to predict whether a patient will have an infiltrate on chest X-ray (CXR). This prospective observational study included patients visiting the Emergency Department of Beilinson Hospital in the years 2003-2004 (derivation cohort) and 2010-2011 (validation cohort), who had undergone a CXR, and were suspected of having a respiratory infection. We excluded all patients with possible healthcare associated infections. A logistic regression model was derived and applied to the validation cohort. A total of 1,555 patients met inclusion criteria: 993 in the derivation cohort and 562 in the validation cohort with 287 (29%) and 226 (40%) having an infiltrate, respectively. The derivation model area-under-the curve (AUC) was 0.79 (95% CI 0.76-0.82). We categorized the patients into three groups-presence or absence of infiltrate, or undetermined. In the validation cohort, 70 (12%) patients were classified as 'no infiltrate'; 3 (4%) of them had an infiltrate, 367 (65%) were classified as 'infiltrate'; 190 (52%) of them had an infiltrate on CXR, and 125 (46%) were classified as 'undetermined'; 33 (26%) of them with an infiltrate on CXR. Using this prediction model for the evaluation of patients with suspected respiratory infection in an ED setting may help avoid over 10% of CXRs. [ABSTRACT FROM AUTHOR]

Background: Traditional wisdom suggests that infections in older patients have atypical presentation, including blunted febrile response. Data are scarce., Design: We analyzed data from a prospectively collected database on presentation of infection in 4,308 patients, and compared the presentation of older patients (≥ 75 years) versus adults (< 75 years)., Settings: Single tertiary medical center., Participants: Patients admitted with suspected bacterial infection during 2002-2004 and 2010-2011., Measurements: We evaluated clinical presentation on day of admission, including vital signs and laboratory parameters., Results: No difference in fever values as a presenting sign of infection was found between older patients and adults (median fever 38.3°C, interquartile range [IQR] 37.4-39.0°C; and 38.4°C, IQR 37.3-39.0°C, respectively, P = 0.08). Median leukocyte count was significantly higher in older patients (median 11.60, IQR 8.30-15.72 in older patients; 10.84, 7.50-15.00 in adults, P < 0.001). Presentation with septic shock, acute renal failure, and reduced consciousness was significantly more common in older patients. These findings were also consistent in the subgroups of bacteremic patients and patients with microbiologically documented infection., Conclusion: Elevated fever and leukocytosis were found to be at least equally common in older patients compared to younger adults as part of the presentation of infection.

Background: Venous thromboembolism (VTE) is a feared complication during hospitalization. The practice of administering pharmacological prophylaxis is highly endorsed despite failure of studies to show reduction in mortality., Aim: : To determine the benefit of VTE prophylaxis in acutely ill medical patients with sepsis., Methods: A prospective cohort, with enrollment between January 2010 and April 2011. Patients were detected in four medicine departments at a university-affiliated hospital and followed for 90 days for pre-specified outcomes. We included all septic patients at high VTE risk defined by Padua score ≥ 4. The primary outcome was 30-day mortality. Incidence of pulmonary embolism, deep vein thrombosis or major bleeding episodes at 30 and 90 days, and 90-day mortality were secondary outcomes., Results: A total of 1540 patients were identified, of which 720 (55%) were at high risk for VTE and included. A total of 213 (29.6%) patients received prophylaxis. VTE occurred in 6 control patients and 2 treated (0.9 and 1.2%, respectively, RR 0.79, CI: 0.16-3.95). Major bleeding events occurred in 4 (0.8%) control and 7 (3.3%) treated patients (RR 4.1, CI: 1.24-14.08, P = 0.01). After adjusting for covariates, VTE prophylaxis conferred no 30- or 90-day mortality benefit (OR 1.24, CI: 0.79-1.93 and OR 1.47, CI: 0.99-2.17, respectively). Lack of significant benefit with prophylaxis persisted after propensity-score matching (OR for 30-day mortality 1.01, CI: 0.66-1.55)., Conclusions: In acutely ill inpatients with sepsis, no significant benefit was demonstrated for VTE prophylaxis, with higher rates of bleeding. The risk-benefit ratio of this intervention should be carefully examined., (© The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objectives: Adherence to scheduled chemotherapy is important for optimal outcomes of cancer patients. We examined causes for delay or cancellation of planned chemotherapy, focusing on mild respiratory infections during the winter., Methods: Prospective cohort study. We included all adults with solid or hematologic cancer receiving active chemotherapy treatment during the winter of 2010-2011 in a cancer center. We compared baseline characteristics and outcomes between patients with and without chemotherapy delays, cancellations, or dose-reductions ("chemotherapy delay")., Results: We included 547 patients receiving chemotherapy during the winter of 2011. Of these, 213 (38.9%) patients experienced 306 episodes of chemotherapy delays. The main documented reasons for the chemotherapy delay were neutropenia (84/306, 27.4%), fever or infection (73/306, 23.9%) and thrombocytopenia (26/306, 8.5%). Independent risk factors for chemotherapy delays were upper respiratory infections (OR 1.87, 95% CI 1.27-2.76), lymphopenia, prior hospitalization, peripheral vascular disease and colon cancer relative to hematologic cancer. In the adjusted analysis focusing on chemotherapy delays due to infection alone, upper respiratory infections (OR 5.25, 95% I 2.81-9.84) and age were significant independent risk factors., Discussion: Mild respiratory infections were associated with chemotherapy delays. Our results should encourage modalities to prevent influenza and other upper respiratory infections among cancer patients., (Copyright © 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved.)

Intravenous (IV) granulocyte colony stimulating factor (G-CSF) might be safer and more convenient than subcutaneous (SC) administration to hospitalized hemato-oncological patients receiving chemotherapy. To compare IV vs. SC G-CSF administration, we conducted a randomized, open-label trial. We included inpatients receiving chemotherapy for acute myeloid leukemia, acute lymphoblastic leukemia, lymphoma or multiple myeloma, and allogeneic or autologous hematopoietic cell transplantation (HCT). Patients were randomized to 5 mcg/kg single daily dose of IV bolus versus SC filgrastim given for its clinical indications. Patients were crossed-over to the alternate study arm on the subsequent chemotherapy course. The primary outcomes were time from initiation of filgrastim to recovery of stable neutrophil count of >500 cells/µL and a composite clinical outcome of infection or death assessed for the first course post-randomization. The study was stopped on the second interim analysis. Of 120 patients randomized, 118 were evaluated in the first treatment course. The mean time to neutropenia resolution was longer with IV G-CSF [7.9 days, 95% confidence interval (CI) 6.6-9.1] compared with SC G-CSF (5.4 days, 95% CI 4.6-6.2), log-rank P = 0.001. Longer neutropenia duration was observed in all patient subgroups, except for patients undergoing autologous HCT. There was no significant difference between groups in the occurrence of infection or death, but more deaths were observed with IV (4/57, 7%) versus SC (1/61, 1.6%) G-CSF administration, P = 0.196. Similar results were observed when all 158 courses following cross-over were analyzed. Patients reported similar pain and satisfaction scores in both groups. Bolus IV administration of G-CSF results in longer neutropenia duration than SC administration, with no difference in clinical or quality-of-life measures., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: Patients with cancer are at increased risk of developing complications of influenza. In this study, the authors assessed the effectiveness of influenza vaccination among cancer patients., Methods: A prospective, noninterventional cohort study was conducted during the 2010 to 2011 influenza season. The cohort included adult cancer patients with solid malignancies who were receiving chemotherapy and hematologic patients who had active disease. Patients who died between October and November 2010 (N = 43) were excluded. A comparison was made between patients who received the 2011 seasonal influenza vaccine with those who did not. The primary outcome was a composite of hospitalizations for fever or acute respiratory infections, pneumonia, and/or infection-related chemotherapy interruptions. All-cause mortality was a secondary outcome. A propensity-matched analysis was conducted based on the propensity for vaccination., Results: Of 806 patients who were included, 387 (48%) were vaccinated. Factors that were associated independently with vaccination included past influenza vaccination, past pneumococcal vaccination, >6 months since cancer diagnosis, country of birth, and cancer type/status. The primary outcome occurred in 111 of 387 (28.7%) vaccinated patients versus 112 of 419 (26.7%) unvaccinated patients (P = .54). No association was observed between vaccination and the primary outcome in a propensity-matched analysis (N = 436) or during peak influenza activity. The mortality rate was 11.9% (46 of 387 patients) in vaccinated patients versus 19.1% (80 of 419 patients) in unvaccinated patients (P = .005). Vaccination retained a significant association with mortality on multivariable analysis (odds ratio, 2.31; 95% confidence interval, 1.4-3.79) and in a propensity-matched analysis (odds ratio, 2.39; 95% confidence interval, 1.32-4.32)., Conclusions: Influenza vaccination was associated with lower mortality among cancer patients, although an association with infection-related complications could not be demonstrated. The current results support efforts to promote influenza vaccination in patients with cancer., (Copyright © 2013 American Cancer Society.)

Objectives: We aimed to examine whether C-reactive protein (CRP) elevation precedes the clinical signs and symptoms of infection among patients undergoing allogeneic hematopoietic cell transplantation (HCT)., Methods: Prospective cohort of patients undergoing allogeneic HCT in whom daily blood samples for CRP were taken. In a nested case-control study, cases were defined as patients with clinically-significant bloodstream infection (BSI). Controls were defined as afebrile patients without infection, matched by age, time after transplantation and GVHD status. We calculated the mean difference (MD) between CRP 1 day before clinical suspicion of infection (day -1) and days -2 and -3 (deltaM1M2 and delta M1M3, respectively) and compared cases vs. controls., Results: From January 2010 to April 2012 we identified 46 cases of BSIs. The difference between the mean delta M1M3 and delta M1M2 in cases and controls were significantly higher in patients with BSI compared to controls (MD = 5.9, 95% CI 3.5-8.3, p < .001 and MD = 4.2 mg/dl, 95% CI 2.2-6.2, p < .001, respectively). In the overall cohort, sensitivity, specificity, positive and negative predictive values of a daily delta value >4 mg/dl were 52%, 98%, 66% and 98%, respectively., Conclusions: A daily increase of CRP blood levels of >4 mg/dl in afebrile HCT recipients should trigger an evaluation for infection., (Copyright © 2013 The British Infection Association. Published by Elsevier Ltd. All rights reserved.)

Surveys of bacterial infections among neutropenic cancer patients frequently report pooled antibiotic susceptibility data. Management guidelines address initial antibiotic regimens for febrile neutropenia. In this study, rates of bacterial infection and antibiotic susceptibilities among initial and subsequent or breakthrough episodes of fever were analysed. Prospective surveillance of fever of unknown origin (FUO), clinically documented infection and microbiologically documented infection (MDI) was conducted in the haemato-oncology and haematopoietic stem cell transplantation wards in a single cancer centre in Israel. Subsequent infections were defined as those developing during or after broad-spectrum antibiotic treatment. A total of 567 febrile episodes were documented among 271 patients. Bacterial MDIs were documented in 104/162 (64%) initial febrile episodes and 75/405 (19%) subsequent episodes and Gram-negative bacteria predominated (64% and 71%, respectively). Escherichia coli was the most common species isolated. Higher antibiotic susceptibilities were observed for initial compared with subsequent MDIs for Gram-negative bacteria [ceftazidime 80% vs. 45%, piperacillin/tazobactam (TZP) 86% vs. 40% and meropenem 95% vs.76%] and Gram-positive bacteria. TZP monotherapy was the most commonly used antibiotic and its susceptibility decreased to 22.2% following its use. Appropriate empirical antibiotic treatment was administered in 71/97 (73%) initial and 40/74 (54%) subsequent episodes (P=0.009) and was significantly associated with mortality (adjusted odds ratio=0.4, 95% confidence interval 0.18-0.87). We conclude that previous antibiotic exposure significantly impacts antibiotic susceptibility and that pooled reporting of all infections can be misleading. Treatment guidelines should address the antibiotic treatment of breakthrough fever., (Copyright © 2012 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.)