Background

The risk of second bacteremia during antibiotic treatment for initial bacteremia is unknown in high-risk populations. Objectives were to describe the prevalence of second bacteremia during treatment and identify risk factors in children with acute myeloid leukemia (AML).

Methods

We conducted a retrospective, population-based cohort study that included children and adolescents with de novo, non-M3 AML who were diagnosed and treated between January 1, 1995 and December 31, 2004 at 15 Canadian centers. Patients were monitored for bacteremia during chemotherapy until completion of treatment, hematopoietic stem cell transplantation, relapse, refractory disease, or death.

Results

There were 290 episodes of bacteremia occurring in 185 (54.3%) of 341 children. Eighteen (6.2%) had a second bacteremia while receiving antibiotic treatment. Two episodes of second bacteremia were complicated by sepsis; there were no infection-related deaths. Eleven episodes (61.1%) had either an initial Gram-positive and subsequent Gram-negative bacteremia or initial Gram-negative followed by Gram-positive bacteremia. Days receiving corticosteroids (odds ratio (OR) 1.09, 95% confidence interval (CI) 1.07-1.12; P<0.0001), cumulative dose of corticosteroids (OR 1.04, 95% CI 1.00-1.08; P=0.035) and days of neutropenia from start of course to initial bacteremia (OR 1.07, 95% CI 1.02-1.12; P=0.007) were significantly associated with second bacteremia.

Conclusion

In pediatric AML, 6% will experience a second bacteremia during antibiotic treatment; duration of corticosteroid exposure and neutropenia are risk factors. These patients remain at high risk for second bacteremia after identification of the initial bacteremia and warrant continued broad-spectrum treatment during profound neutropenia.

Abbreviations

CONS: coagulase negative Staphylococcus ; VGS: viridans group Streptococcus; Amp: ampicillin; Cz: ceftazidime;

Cef: cefotaxime; Cipro: ciprofloxacin; Clin: clindamycin; Clox: cloxacillin; G: gentamicin; Metro: metronidazole; Mero: meropenem;

O: oxacillin; Pip: piperacillin; Ta: piperacillin/tazobactam; Tm:ticarcillin/clavulanate; To: tobramycin; V: vancomycin.

Table 1

Detailed Description of 18 Episodes of Second Bacteremia During Antibiotic Treatment

First BacteremiaInitial AntibioticsAntibiotics 1 Day Prior to Second BacteremiaSecond BacteremiaDays Between BacteremiasDays of FeveraDays of NeutropeniabDays Broad Spectrum Antibioticsb
VGS* V-Cz-To V-Mero-To CONS 2 2 15 14 
VGS Cipro-G G-Clin-Cipro CONS 3 3 4 3 
VGS Pip-To-Clox Pip-To-O CONS 13 0 16 13 
VGS V-Ta-G V-Ta-Cipro Corynebacterium jeikeium 9 4 19 9 
VGS V-Cz V-Cz-Metro Enterobacter cloacae *,+ 3 3 36 28 
VGS Pip-To-Clox V-To Fusobacterium spp 5 5 18 15 
VGS Pip-To-Clox Pip-To-Clox K. pneumonia+ 2 2 2 2 
VGS Pip-G Cef-G P. aeruginosa*,+ 6 0 18 16 
Leuconostoc spp Amp-Clox-To V-Cz-Metro E. cloacae 12 1 29 23 
Actinobacter spp* Pip-To-Clox Pip-To-Clox Enterococcus faecalis 1 0 55 45 
Klebsiella pneumoniae Mero Mero-To CONS 3 3 6 3 
Escherichia coli* Pip-To-Clox Pip-To-Clox-Metro CONS 7 0 10 7 
E. coli* Tm-G Mero-G-Metro Enterococcus spp 11 0 16 11 
E. coli Amp-Clox-To Mero Leuconostoc spp 9 9 28 30 
E. coli Cz-To Cz-To Clostridium tertium 4 0 6 4 
E. coli Pi-To V-Mero-Metro Stenotrophomonas maltophilia+ 8 1 21 21 
Fusobacterium spp Pip-To-Clox V-To Capnocytophaga spp 2 2 20 15 
Pseudomonas aeruginosa* Tm-To Tm-To VGS 8 0 11 8 
First BacteremiaInitial AntibioticsAntibiotics 1 Day Prior to Second BacteremiaSecond BacteremiaDays Between BacteremiasDays of FeveraDays of NeutropeniabDays Broad Spectrum Antibioticsb
VGS* V-Cz-To V-Mero-To CONS 2 2 15 14 
VGS Cipro-G G-Clin-Cipro CONS 3 3 4 3 
VGS Pip-To-Clox Pip-To-O CONS 13 0 16 13 
VGS V-Ta-G V-Ta-Cipro Corynebacterium jeikeium 9 4 19 9 
VGS V-Cz V-Cz-Metro Enterobacter cloacae *,+ 3 3 36 28 
VGS Pip-To-Clox V-To Fusobacterium spp 5 5 18 15 
VGS Pip-To-Clox Pip-To-Clox K. pneumonia+ 2 2 2 2 
VGS Pip-G Cef-G P. aeruginosa*,+ 6 0 18 16 
Leuconostoc spp Amp-Clox-To V-Cz-Metro E. cloacae 12 1 29 23 
Actinobacter spp* Pip-To-Clox Pip-To-Clox Enterococcus faecalis 1 0 55 45 
Klebsiella pneumoniae Mero Mero-To CONS 3 3 6 3 
Escherichia coli* Pip-To-Clox Pip-To-Clox-Metro CONS 7 0 10 7 
E. coli* Tm-G Mero-G-Metro Enterococcus spp 11 0 16 11 
E. coli Amp-Clox-To Mero Leuconostoc spp 9 9 28 30 
E. coli Cz-To Cz-To Clostridium tertium 4 0 6 4 
E. coli Pi-To V-Mero-Metro Stenotrophomonas maltophilia+ 8 1 21 21 
Fusobacterium spp Pip-To-Clox V-To Capnocytophaga spp 2 2 20 15 
Pseudomonas aeruginosa* Tm-To Tm-To VGS 8 0 11 8 
a

Days of continuous fever prior to second bacteremia

b

Days from start of course to second bacteremia

*

Episode associated with sepsis

+

Gram-negative organism resistant to either meropenem and/or piperacillin

View Large
Disclosures:

No relevant conflicts of interest to declare.

Topics:
antibiotics, bacteremia, child, infections, leukemia, myelocytic, acute, metronidazole, ciprofloxacin, neutropenia, adrenal corticosteroids, glucocorticoids

Author notes

*

Asterisk with author names denotes non-ASH members.

© 2013 by The American Society of Hematology
2013
Sign in via your Institution