CHAPTER 11. Intravascular Device-Related Infections Catheter Salvage Strategies and Prevention of Device-Related Infection by Nasia Safdar, Dennis G. Maki

/in , /by

ABSTRACT

The use of intravascular devices for administration of chemotherapeutic drugs, fluids, blood products and nutritional support is essential to the care of patients with cancer. Unfortunately, intravascular devices have great potential to produce iatrogenic disease, especially bloodstream infection originating from colonization of the device used for access or from contamination of the infusate administered through the device. Over two-thirds of all healthcare-associated bacteremias originate from devices for vascular access. Probably more than any other healthcare-associated infection, IVDR BSI  is eminently preventable. The first step to preserve vascular access is a highly effective institutional program for prevention of IVDR BSI. In recent years, high-quality research studies have delineated key measures for prevention, such as chlorhexidine for cutaneous antisepsis, maximal barrier precautions, antiinfective-impregnated catheters, and the use of a CVC insertion “bundle” , and IVDR BSI rates in the ICU have declined markedly in most  hospitals. However, despite adherence to best practices, IVDR BSI continues to pose formidable challenges, especially in patients with cancer. Catheter salvage in the context of established IVDR BSI is particularly challenging but recent advances such as antibiotic lock technique are now providing previously unavailable options.

CHAPTER 10. Catheter-Related Infections in Cancer Patients by Iba Al Wohoush, Anne-Marie Chaftari, Issam Raad

/in , /by

ABSTRACT

Central venous catheters (CVCs) play a major role in the management of high-risk patients, particularly cancer patients and are mainly used for the administration of anti cancer agents, antibiotics, and blood products. CRBSI rates are influenced by patient related factors, such as type and severity of the illness, by catheter related factors, and institutional factors (e.g. bed size and academic affiliation).  Catheter related infections could be local, such as exit site, tunnel, and pocket infections; or systemic such as catheter related bloodstream Infection. Many diagnostic methods have been developed, some of which require catheter removal, whereas others do not. Strategies for prevention and management of CRBSI are presented in this chapter.

 

CHAPTER 9. Controversies in Empiric Therapy of Febrile Neutropenia by John R. Wingard

/in , /by

ABSTRACT

 Anti-neoplastic chemotherapy regimens induced myelosuppression was quickly recognized as a major limitation to the full utility of cytotoxic drug regimens targeting cancer.  Measures taken to mitigate harm from myelosuppression have led to a number of controversies over the years. The first controversy faced by clinicians was whether or not empiric antibiotic therapy for febrile neutropenia is appropriate.  The reasoning was that fever may be due to non-infectious causes, inappropriate antibiotic use might lead to emergence of resistance or superinfections by resistant organisms, the patient might experience toxicities (the antibiotics of those days had considerable toxicity), and the drugs were costly.   This controversy was eventually resolved in favor of empiric antibiotics through a series of studies.  Today, there are yet other controversies about empiric therapy of febrile neutropenia.  These include questions as to whether there is an optimal antibiotic regimen, persistent concerns about resistance, questions as to what are the causes for fevers that have no apparent explanation, quandaries about the role for empiric antifungal therapy, and the unresolved issues as to why some patients become quite ill while others are less affected. Yet other controversies as to optimal management of venous catheters, etiology of neutropenic enterocolitis (typhlitis), the role for antimicrobial prophylaxis, and antibiotic resistance are addressed in other chapters and will not be covered here.

CHAPTER 8. Management of the Neutropenic Patient with Fever by Kenneth V. I. Rolston, Gerald P. Bodey

/in , /by

 ABSTRACT

Neutrophils provide protection against a wide variety of common and opportunistic bacterial and fungal pathogens. Consequently, the frequency and severity of infections caused by these organisms is increased in patients with neutropenia.  At most cancer treatment centers, gram-positive organisms are isolated more frequently from neutropenic patients with documented bacterial infections than gram-negative bacilli, although institutional and regional differences occur as do periodic shifts in the spectrum of bacterial infections. Candida spp. and Aspergillus spp. remain the most common fungal pathogens in this setting, although a number of opportunistic fungal pathogens have emerged.  The prompt administration of empiric, broad-spectrum, parenteral antibiotics in the hospital when a neutropenic patient becomes febrile is the standard of care. Over the past decade it has become possible to reliably identify “low-risk” neutropenic patients both in adult and pediatric patient populations. Infection prevention (prophylaxis), infection control, and antimicrobial stewardship are important aspects in the overall management of the febrile neutropenic patient.

CHAPTER 7. Management of Infections in Critically Ill Cancer Patients By Jason M. Blaylock, Catherine F. Decker, Henry Masur

/in /by

ABSTRACT

Advances in critical care medicine have enabled cancer patients to survive aggressive medical and surgical therapies that they could not have tolerated a decade ago. For patients whose goals can be met by ICU support, the diagnostic and empiric therapeutic approach will be far different than when patients are more stable in other hospital areas: evaluations must be completed rapidly while patients are able to tolerate such testing, and empiric therapy must be broad and promptly administered. Oncologists and infectious disease specialists need to be actively involved in evaluating cancer patients in the ICU and in developing their management plans due to the enhanced knowledge they are likely to have for the patient’s history prior to the ICU, for their knowledge of the underlying disease and life-threatening process, and for their expertise in drug selection and monitoring.

CHAPTER 6. Surgery-Related Infections in Cancer Patients By Emilio Bouza, Almudena Burillo, Juan Carlos Lopez-Gutierrez, José F. Tomás

/in /by

ABSTRACT

Many different infections may occur after surgical events in patients with solid tumors, though infections of the operative site are the most common nosocomial infections in any surgical patient. Also frequent, are infections of the lower respiratory tract, related or not to endotracheal intubation; of the urinary tract, usually related to the need for bladder or other urinary catheters; and bloodstream infections, mainly related to the use of intravascular catheters. This chapter reviews and discusses SSI produced after surgery for the most common tumors paying special attention to incidence, common clinical presentations and risk factors, diagnostic alertness, therapeutic principles and particular aspects of prophylaxis if pertinent. Due to the existing variety of tumors and surgical procedures, we first address –from head to limbs– the most common tumors requiring surgery in adults and end the chapter with a section in which SSI are described in child cancer and compared to the situation in adults.

CHAPTER 5. Infections in Patients with Hematologic Malignancies Treated with Monoclonal Antineoplastic Therapy by André Goy, Susan O’Brien

/in /by

ABSTRACT

The advent of monoclonal antibody therapy heralded a new era in oncology. In 1997, rituximab became the first monoclonal antibody for the treatment of cancer following its approval for patients with B-cell non-Hodgkin’s lymphoma. The potential risks of any pharmacotherapy should be considered alongside the obvious benefits. Recently, concerns have emerged over the possible increase in infectious complications associated with monoclonal antibodies compared with traditional chemotherapy. Due to the nature of the malignancies that they target, most of the monoclonal antibodies currently in use for the treatment of hematologic cancers are directed at specific surface markers on B or T cells. Consequently, the risk of infectious complications with these monoclonal antibodies is of particular concern and a comprehensive review of these complications is presented in this chapter.

CHAPTER 4. Infections in Solid Organ Cancer by Alison Freifeld

/in /by

ABSTRACT

Over 90% of the 1.4 million new cases of cancer diagnosed in the US in 2008 were due to solid tumors, with predominant sites being lung, breast, prostate, colorectal, bladder and uterine cancers While it is clear to practicing oncologists that solid tumor patients are generally at lower risk for infection-related complications overall, infections are certainly not rare in this population.  Common foci include intravascular catheter-related bacteremia, pneumonias, wound and skin/soft tissue infections and fever associated with chemotherapy-induced neutropenia.  Nonetheless, there is little published data examining the incidence or characteristics of infections in solid tumor patients.  This is not only because infection is relatively uncommon in solid tumor patients, but also because sites, pathogens and severity will vary, to a large extent, with tumor location, natural history and the type and intensity of anticancer therapy. This variability precludes a neat summary of all the bacterial, viral and fungal infections that occur in the solid tumor group as a whole.  Instead, observational series and anecdotal reports have lead to the recognition of patterns of infection that may be considered “typical” for specific solid tumor types, or that are associated with certain anti-tumor treatment regimens.  The goal of this chapter is to familiarize the physician with these infection profiles so they may to identify and manage them promptly and effectively.

CHAPTER 3. Infections in Patients with Hematologic Malignancies by Genovefa Papanicolaou, Jayesh Mehta

/in /by

ABSTRACT

Hematologic malignancies are a heterogeneous group of diseases with differing clinical manifestations, disease course, response to therapy, and long-term outcome.  More intensive therapies are also being extended to older age groups and to patients with significant comorbidities which were traditionally excluded from such treatment. These intensive treatment approaches are associated with multiple complications; infections from a wide variety of pathogenic and opportunistic organisms being amongst the commonest and the most serious. Infections affect quality of life, delay potentially saving chemotherapy and pose a substantial burden for the health care system.  Infection still remains an important cause of death for patients with hematologic malignancies.

CHAPTER 2. Infections in Hematopoietic Stem Cell Transplant Recipients by Georg Maschmeyer, Per Ljungman

/in /by

ABSTRACT

The risk of infection among allogeneic hematopoietic stem cell transplant (aHSCT) recipients is determined by patient age, underlying disease, the complications that occurred during preceding treatment regimens, the selected transplantation modality, and the severity of graft-versus-host disease. Immunological reconstitution after hematopoietic recovery has an impact on type of post-transplant infectious complications, and infection-related mortality is significantly higher post-engraftment than during the short post-transplant neutropenia. As different pathogenetic and epidemiological backgrounds of infections occur following aHSCT, three consecutive time periods post-transplant are separately described: the early post-transplant period (pre-engraftment, comprising 3 weeks), the intermediate post-transplant period (3 weeks to three months) and the late post-transplant period (later than day + 90).