- Email: [email protected]
Duration of empiric antibiotic therapy in granulocytopenic patients with cancer
Empirie antibiotic therapy
Granulocytopenia Infectious complications
Cancer Compromised host
Bleeding disorder
Hemostasis
Described is a 34 year old woman with a moderate to severe bleeding disorder in whom impaired platelet procoagulant activity (PPA) was found by several methods, including tests of factor 3 availability (PF-3a). prothrombin consumption and contact activation. No deficiencies of ptatelet adhesion, aggregation, secretion, metabolism or granule-bound substances were detectable. Under adequate platelet coverage, she underwent two surgical procedures without difficulty. These findings demonstrate the role of PPA in hemostasis and indicate that a defect in PPA can be an isolated occurrence. The abnormalities in PF-3a found in this patient could be due to the diminished number of factor V binding sites, resulting in impaired factor Xa binding, found in separate studies by Majerus et al.
Platelet procoagulant acttvity
The bone marrow granulocyte reserves of nine black patients with “benign” neutropenia were estimated by measuring the maximum neutrophil increment after the administration of hydrocortisone. Thirty control subjects, including 16 black and 14 white adults, were also studied. The mean neutrophil increment in the black patients with neutropenia was significantly less than that of the control subjects. These data suggest that there is a subpopulation of healthy black adults with neutrophil counts below 2,OOO/pl with reduced marrow granulocyte reserves as tested by corticosteroids Bone marrow aspirates in four of the neutropenic patients showed normal cellularity and myeloid maturation suggesting that the lower increments are due to a dilference in granulocyte release rather than to a difference in granulocyte production.
Marrow granulocyte reserve
Weiss HJ, Vicic WJ, Lages BA, Rogers J: Isolated deficiency of platelet procoaguiant activity. Am J Med 67: 206-213, l979.
Leukopenia
Mason BA, Lessin L. Schechter GP: Marrow granulocyte reserves in Black Americans. Am J Med 67:201-205,1979.
Neutropenia
Leukocytes
The optimal duration of empiric antibiotic therapy in the febrile granulocytopenic patient vrith cancer when no infectious source can be identified is unknown. Studied prospectively were 306 episodes of fever and granulocytopenia in 143 patients (aged one to 33 years) with leukemia or solid tumor. Eligible patients had an extensive diagnostic evaluation and were then treated empirically with Keflin@, gentamicin and carbenicillin (KGC). Initial evaluation failed to identify an infectious etiology for the fever in 142 of the 306 episodes. After seven days of empiric KGC therapy, patients with a fever of unknown origin (FUO) who had become afebrile but whose poiymorphonuclear leukocytes were <500/mm3 were randomized to either continue or discontinue (d/c) KGC therapy. In seven of 17 patients randomized to d/c KGC, infectious sequelae developed (p = 0.007) within a median of two days of discontinuin$ KGC therapy. None of the patients had a resistant microbial flora or superinfection. These data suggest that the patient with a FUO who becomes afebrile during empiric antibiotic therapy may profit from continued therapy.
Fever of unknown origin
Eighty-seven patients with newly diagnosed Hodgkin’s disease, pathologic stages IA, IIA, IIB and IIIA, were assigned at random to receive extended field radiotherapy alone or that therapy followed by six cycles of MOPP chemotherapy. Patients were followed for a median of 69-k months from the end of all treatments. Patients whose disease-was less than stage IIIA had a 31 per cent relapse rate with radiotherapy alone compared to a 6 per cent relapse rate with combined modality treatment (P = 0.04). No deaths from Hodgkin’s disease have occurred in patients who received combined modality therapy, whereas 24 per cent of the patients given radiotherapy alone have died with active disease. However three patients with stage IIIA disease treated with both modalities have died from other causes. Combined modality therapy of patients with early Hodgkin’s disease may be superior to radiotherapy alone, especially for certain subgroups of patients discussed in detail.
Combined modality treatment
Pizza PA, Robichaud EJ, Gill FA, et al.: Duration ofiempiric antibiotic therapy in granulocytopenic patients with cancer. Am J Med 67: 194-200, 1979.
Radlotherapy
Wiernik PH, Gustafson J, Schimpff SC, Diggs CH: Combined modality treatment of Hodgkin’s disease confined to lymphnodes. Results eight years later. Am J Med 67: 163-193.1979
Hodgkin’s disease
_
Granulocytopenia Infectious complications
Cancer Compromised host
Bleeding disorder
Hemostasis
Described is a 34 year old woman with a moderate to severe bleeding disorder in whom impaired platelet procoagulant activity (PPA) was found by several methods, including tests of factor 3 availability (PF-3a). prothrombin consumption and contact activation. No deficiencies of ptatelet adhesion, aggregation, secretion, metabolism or granule-bound substances were detectable. Under adequate platelet coverage, she underwent two surgical procedures without difficulty. These findings demonstrate the role of PPA in hemostasis and indicate that a defect in PPA can be an isolated occurrence. The abnormalities in PF-3a found in this patient could be due to the diminished number of factor V binding sites, resulting in impaired factor Xa binding, found in separate studies by Majerus et al.
Platelet procoagulant acttvity
The bone marrow granulocyte reserves of nine black patients with “benign” neutropenia were estimated by measuring the maximum neutrophil increment after the administration of hydrocortisone. Thirty control subjects, including 16 black and 14 white adults, were also studied. The mean neutrophil increment in the black patients with neutropenia was significantly less than that of the control subjects. These data suggest that there is a subpopulation of healthy black adults with neutrophil counts below 2,OOO/pl with reduced marrow granulocyte reserves as tested by corticosteroids Bone marrow aspirates in four of the neutropenic patients showed normal cellularity and myeloid maturation suggesting that the lower increments are due to a dilference in granulocyte release rather than to a difference in granulocyte production.
Marrow granulocyte reserve
Weiss HJ, Vicic WJ, Lages BA, Rogers J: Isolated deficiency of platelet procoaguiant activity. Am J Med 67: 206-213, l979.
Leukopenia
Mason BA, Lessin L. Schechter GP: Marrow granulocyte reserves in Black Americans. Am J Med 67:201-205,1979.
Neutropenia
Leukocytes
The optimal duration of empiric antibiotic therapy in the febrile granulocytopenic patient vrith cancer when no infectious source can be identified is unknown. Studied prospectively were 306 episodes of fever and granulocytopenia in 143 patients (aged one to 33 years) with leukemia or solid tumor. Eligible patients had an extensive diagnostic evaluation and were then treated empirically with Keflin@, gentamicin and carbenicillin (KGC). Initial evaluation failed to identify an infectious etiology for the fever in 142 of the 306 episodes. After seven days of empiric KGC therapy, patients with a fever of unknown origin (FUO) who had become afebrile but whose poiymorphonuclear leukocytes were <500/mm3 were randomized to either continue or discontinue (d/c) KGC therapy. In seven of 17 patients randomized to d/c KGC, infectious sequelae developed (p = 0.007) within a median of two days of discontinuin$ KGC therapy. None of the patients had a resistant microbial flora or superinfection. These data suggest that the patient with a FUO who becomes afebrile during empiric antibiotic therapy may profit from continued therapy.
Fever of unknown origin
Eighty-seven patients with newly diagnosed Hodgkin’s disease, pathologic stages IA, IIA, IIB and IIIA, were assigned at random to receive extended field radiotherapy alone or that therapy followed by six cycles of MOPP chemotherapy. Patients were followed for a median of 69-k months from the end of all treatments. Patients whose disease-was less than stage IIIA had a 31 per cent relapse rate with radiotherapy alone compared to a 6 per cent relapse rate with combined modality treatment (P = 0.04). No deaths from Hodgkin’s disease have occurred in patients who received combined modality therapy, whereas 24 per cent of the patients given radiotherapy alone have died with active disease. However three patients with stage IIIA disease treated with both modalities have died from other causes. Combined modality therapy of patients with early Hodgkin’s disease may be superior to radiotherapy alone, especially for certain subgroups of patients discussed in detail.
Combined modality treatment
Pizza PA, Robichaud EJ, Gill FA, et al.: Duration ofiempiric antibiotic therapy in granulocytopenic patients with cancer. Am J Med 67: 194-200, 1979.
Radlotherapy
Wiernik PH, Gustafson J, Schimpff SC, Diggs CH: Combined modality treatment of Hodgkin’s disease confined to lymphnodes. Results eight years later. Am J Med 67: 163-193.1979
Hodgkin’s disease
_