Chemotherapy
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Lower respiratory tract infections are the major cause of death due to infectious disease in the developed and developing world. Despite substantial progress in defining pathogens and in therapeutic options, there continues to be major controversies in the clinical management of these infections. This report reviews the guidelines for community-acquired pneumonia from the Infectious Diseases Society of America (IDSA), updated from the initial publication. ⋯ Clinical trials have shown equivalence or superiority compared to other standard agents. They are well tolerated, and can be administered intravenously or orally, once daily. A recent retrospective review has shown superior outcome with fluoroquinolone treatment compared to cephalosporins, including a 36% reduction in mortality.
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A multiple-antibiotic-resistant (MAR) strain of Klebsiella pneumoniae was introduced into a pediatric ward and subsequently colonized neonates of two wards with several cases of systemic infection. This strain produced an extended-spectrum beta-lactamase and was resistant to cefotaxime, ceftazidime, and, among others, all aminoglycosides including amikacin. ⋯ The strain was susceptible to the innate antibacterial systems operative in fresh defibrinated blood from two adults. Combined human blood/antimicrobial drug assays documented the in vitro bactericidal activity of carbapenems (meropenem was slightly more effective than imipenem), fluoroquinolones (ciprofloxacin and trovafloxacin), and polymyxin B against this MAR strain of K. pneumoniae.
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The rates of fungal infections have increased substantially in Europe as well as in North America. Most frequently Aspergillus spp. and Candida spp. are isolated. Despite the recent introduction of new azoles and lipid-based formulations of amphotericin B, there are relatively few randomized, controlled studies on the use of antifungal drugs in patients with hematological malignancies and invasive fungal infections. ⋯ In this situation, lipid formulations of amphotericin B seem to be attractive, since the use of these drugs has been shown to be safe and effective. Considerably higher medical costs limit broader application of lipid formulations of amphotericin B. Because of the rapidly increasing incidence of serious fungal infections, we have reviewed current strategies and the role of newer antifungal drugs for the treatment of deep-organ infections.
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We studied the safety of low-dose amphotericin B lipid complex (ABLC, at 1 mg/kg/day) in 30 persistently febrile (>38 degrees C for at least 5 days or with recurrent fever after 3 days of apyrexia) and neutropenic (<0.5 x 10(9)/l) adult patients with hematologic malignancies. The median age was 45 years (range 18-67), most (60%) had an acute leukemia and all had fever of unknown origin (FUO). The total duration of neutropenia was a median of 17 days (range 9-33), and the total number of days with fever 10 days (range 6-39). ⋯ Response to treatment (defervescence within 6 days without developing a fungal or nonfungal infection) was seen in 22 cases (73%, 95% CI 58-89%), while 8 episodes were considered treatment failures: 2 due to persistent FUO, 1 withdrew due to IRAE, 2 developed nonfungal infections and 3 developed a presumed or definite invasive mycosis. We conclude that low-dose ABLC is very safe and well tolerated and seems as effective as c-AmB for this indication. Thus, randomized trials at this dose level appear justified to demonstrate any real benefit over c-AmB or other lipid formulations for the treatment of FUO in neutropenic patients.