Abstract

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 Bacteremia Initial Antibiotics Antibiotics 1 Day Prior to Second Bacteremia Second Bacteremia Days Between Bacteremias Days of Fevera Days of Neutropeniab Days Broad Spectrum Antibioticsb 
VGS* V-Cz-To V-Mero-To CONS 15 14 
VGS Cipro-G G-Clin-Cipro CONS 
VGS Pip-To-Clox Pip-To-O CONS 13 16 13 
VGS V-Ta-G V-Ta-Cipro Corynebacterium jeikeium 19 
VGS V-Cz V-Cz-Metro Enterobacter cloacae *,36 28 
VGS Pip-To-Clox V-To Fusobacterium spp 18 15 
VGS Pip-To-Clox Pip-To-Clox K. pneumonia+ 
VGS Pip-G Cef-G P. aeruginosa*,18 16 
Leuconostoc spp Amp-Clox-To V-Cz-Metro E. cloacae 12 29 23 
Actinobacter spp* Pip-To-Clox Pip-To-Clox Enterococcus faecalis 55 45 
Klebsiella pneumoniae Mero Mero-To CONS 
Escherichia coli* Pip-To-Clox Pip-To-Clox-Metro CONS 10 
E. coli* Tm-G Mero-G-Metro Enterococcus spp 11 16 11 
E. coli Amp-Clox-To Mero Leuconostoc spp 28 30 
E. coli Cz-To Cz-To Clostridium tertium 
E. coli Pi-To V-Mero-Metro Stenotrophomonas maltophilia+ 21 21 
Fusobacterium spp Pip-To-Clox V-To Capnocytophaga spp 20 15 
Pseudomonas aeruginosa* Tm-To Tm-To VGS 11 
First Bacteremia Initial Antibiotics Antibiotics 1 Day Prior to Second Bacteremia Second Bacteremia Days Between Bacteremias Days of Fevera Days of Neutropeniab Days Broad Spectrum Antibioticsb 
VGS* V-Cz-To V-Mero-To CONS 15 14 
VGS Cipro-G G-Clin-Cipro CONS 
VGS Pip-To-Clox Pip-To-O CONS 13 16 13 
VGS V-Ta-G V-Ta-Cipro Corynebacterium jeikeium 19 
VGS V-Cz V-Cz-Metro Enterobacter cloacae *,36 28 
VGS Pip-To-Clox V-To Fusobacterium spp 18 15 
VGS Pip-To-Clox Pip-To-Clox K. pneumonia+ 
VGS Pip-G Cef-G P. aeruginosa*,18 16 
Leuconostoc spp Amp-Clox-To V-Cz-Metro E. cloacae 12 29 23 
Actinobacter spp* Pip-To-Clox Pip-To-Clox Enterococcus faecalis 55 45 
Klebsiella pneumoniae Mero Mero-To CONS 
Escherichia coli* Pip-To-Clox Pip-To-Clox-Metro CONS 10 
E. coli* Tm-G Mero-G-Metro Enterococcus spp 11 16 11 
E. coli Amp-Clox-To Mero Leuconostoc spp 28 30 
E. coli Cz-To Cz-To Clostridium tertium 
E. coli Pi-To V-Mero-Metro Stenotrophomonas maltophilia+ 21 21 
Fusobacterium spp Pip-To-Clox V-To Capnocytophaga spp 20 15 
Pseudomonas aeruginosa* Tm-To Tm-To VGS 11 
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

Disclosures:

No relevant conflicts of interest to declare.

Author notes

*

Asterisk with author names denotes non-ASH members.