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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 medstore-online.com
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
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