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SUPPORTIVE CARE OF CHILDREN WITH CANCER: FEVER MANAGEMENT AND ANTIBIOTICS

A.     The choice of antibiotics (antimicrobials) to be used at an

institution should be determined by the needs of the patient

and the local patterns of infection and resistance to antibiotics. The underlying disease, the chemotherapy being

used, theprophylactic antimicrobials taken, and the prevalent microorganismsin the hospital, community, and geo-

graphical area are factors that affect the empirical choice of

initial antimicrobials. The presence of a central venous

access device, recent invasive procedures such as a bone

marrow puncture, spinal tap, endoscopy, drug allergy, renal

or hepatic dyfunction, and other drugs that may affect hearing and kidney or liver function will influence the choice of

antimicrobial.

B.     Many combinations of antimicrobials are effective. Prevailing community microorganisms and their antibiotic sensitivity will direct the choices and combinations of

antibiotics. The patient with severe mucositis or the patient who has recently developed a neoplasm of the gastrointestinal or genitourinary tract should receive coverage for anaerobic bacteria. Various combinations that are used are listed below. For help in making a selection, remember that drug resistance is a major problem and refrain from using vancomycin initially unless the clinical situation mandates its use.

1. Aminoglycoside plus an antipseudomonal b- lactam drug

a. Advantages

i.     Good gram-negative coverage

ii.     Synergism against some gram-negative bacilli

iii.     Minimal emergence of resistance

iv. Some anaerobic activity

b. Disadvantages

i.     Lack of activity against some gram-positive bacteria

ii.     Nephrotoxic and ototoxic

iii.     Hypokalemia

iv.     Anaerobic coverage not optimal

v.     Necessity to monitor serum aminoglycoside levels

2.     Combination of two b-lactam drugs

a.     Advantages

i.     Good gram-negative coverage

ii.     Synergism against some gram-negative bacteria

iii.     Low toxicity without need to monitor drug levels

b.     Disadvantages

i.     Possible antagonism with some combinations

ii.     Anaerobic coverage not optimal

iii.     Lack of activity against some gram-positive bacteria

iv.     High cost

3.     Penicillinase-resistant penicillin or vancomycin plus

aminoglycoside and b-lactam drug

a.     Advantages

i.     Broad gram-positive effectiveness

ii.     Good gram-negative coverage

iii.     Synergism against gram-negative bacteria

iv.     Minimal emergence of resistance

v.     Some anaerobic activity

b.     Disadvantages

i.     Combination without vancomycin has suboptimal

effectiveness against S. epidermidis.

ii.     Nephrotoxic and ototoxic, especially with vancomycin

iii.     Hypokalemia

iv.     Anaerobic coverage not optimal

v.     Necessity to monitor serum aminoglycoside and

vancomycin levels

vi.     High cost, especially with vancomycin

4.     Monotherapy with third-generation cephalosporin or

imipenem/cilastatin

a. Advantages

i.     Less toxic than other combinations

ii.     Fairly-good broad-spectrum activity against gram-

positive, gram-negative, and anaerobic bacteria

(imipenem)

b. Disadvantages

i.     Insufficient gram-positive and anaerobic effective-

ness (ceftazidime)

ii.     Potential for b-lactam resistance

iii.     Lack of synergistic activity

iv.     Anaerobic coverage not optimal

5. Third-generation cephalosporin plus penicillinase-resistant penicillin or vancomycin

a.     Advantage

Wide antibacterial coverage, including gram-positive organisms

b.     Disadvantages

i.     Combination without vancomycin has suboptimal

effectiveness against S. epidermidis

ii.     Lack of synergism against gram-negative bacteria

iii.     Necessity to monitor vancomycin levels

iv.     Nephrotoxic and ototoxic with vancomycin

v.     Expensive

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Cancer