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Management of Genitourinary Tract Infections

  • Amar Safdar
  • Maurie Markman
Chapter
Part of the Current Clinical Oncology book series (CCO)

Abstract

The risk of developing an infection in patients with genitourinary tract malignancy arise from a host of factors such as: (1) tumor encroachment and invasion of adjacent structures; (2) tumor necrosis; (3) complications arising from antineoplastic chemotherapy; (4) early and late effects of abdomiopelvic radiation therapy; (5) surgical tumor excision and removal of internal organs; (6) structural abnormalities resulting from surgical diversion procedures; and (7) other causes that disrupt protective barriers in urinary and female reproductive tract. The spectrum of causative organisms most frequently arise from patients’ endogenous microflora. The vagina, lower urinary and intestinal tract colonization with bacteria and yeast serves as important sources for infection. The normal aerobic and anaerobic vaginal bacterial flora may be altered in patients undergoing antineoplastic therapy. Among factors that influence changes in colonization includes, hormonal dysfunction, frequent exposure to broad-spectrum antimicrobial agents, antineoplastic therapy, hospitalization, and instrumentization. Peritonitis, intraabdominal abscess, complicated urinary tract infection, surgical wound infection, skin and soft tissue infection such as cellulitis, necrotizing fasciitis, clostridial myonecrosis, and septic pelvic thrombophlebitis are important infectious complications encountered in patients with genitourinary tract malignancies.

Keywords

Genitourinary tract Cancer Peritonitis Intraabdominal abscess Urinary tract infection Surgical wound infection Cellulitis Necrotizing fasciitis Clostridial myonecrosis Septic pelvic thrombophlebitis 

Notes

Acknowledgement

The authors are grateful to Drs. Donald Armstrong and Kent Sepkowitz of Memorial Sloan-Kettering Cancer Center for their contribution to this chapter.

References

  1. 1.
    Safdar A, Armstrong D. Infections in patients with neoplastic diseases. In: Grenvik M, Ayers SM, Holbrook PR, Shoemaker WC, editors. Textbook of critical care. 4th ed. Philadelphia: W.B. Saunders; 2000. p. 715–26.Google Scholar
  2. 2.
    Safdar A, Armstrong D. Infectious morbidity in critically ill patients with cancer. Crit Care Clin. 2001;17:531–70.PubMedCrossRefGoogle Scholar
  3. 3.
    Evaldson G, Heimdahl A, Kager L, et al. The normal human anaerobic microflora. Scand J Infect Dis. 1982;35:9–15.Google Scholar
  4. 4.
    Rolston KVI, Bodey GP, Safdar A. Polymicrobial infection in patients with cancer: an underappreciated and underreported entity. Clin Infect Dis. 2007;45:228–33.PubMedCrossRefGoogle Scholar
  5. 5.
    Barton DPJ, Fiorica JV, Hoffman MS, et al. Cervical cancer and tubo-ovarian abscesses: a report of three cases. J Reprod Med. 1993;38:561–4.PubMedGoogle Scholar
  6. 6.
    Imachi M, Tanaka S, Ishikawa S, et al. Spontaneous perforation of pyometra presenting as generalized peritonitis in a patient with cervical cancer. Gynecol Oncol. 1993;50:384–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Protopappas AG, Diakomanolis ES, Milingos SD, et al. Tubo-ovarian abscess in postmenopausal women: gynecological malignancy until proven otherwise. Eur J Obstet Gynecol Reprod Biol. 2004;114:203–9.CrossRefGoogle Scholar
  8. 8.
    Inagaki J, Rodriguez V, Bodey GP. Causes of death in cancer patients. Cancer. 1974;33:568–73.PubMedCrossRefGoogle Scholar
  9. 9.
    Iatrakis G, Sakellaropoulos G, Georgoulias N, et al. Gynecologic cancer and surgical infectious morbidity. Clin Exp Obstet Gynecol. 1998;25:36–7.PubMedGoogle Scholar
  10. 10.
    Chang HK, Lo KY, Chiang HS. Complications of urinary diversion after pelvic exenteration for gynecological malignancy. Int Urogynecol J. 2000;11:358–60.CrossRefGoogle Scholar
  11. 11.
    Wydra D, Emerich J, Sawicki S, et al. Major complications following exenteration in cases of pelvic malignancies: a 10-year experience. World J Gastroenterol. 2006;12:1115–9.PubMedGoogle Scholar
  12. 12.
    Matar MJ, Safdar A, Rolston KV. Relationship of colonization with vancomycin-resistant enterococci and risk of systemic infection in patients with cancer. Clin Infect Dis. 2006;42:1506–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Gould N, Kamelle S, Tillmanns T, et al. Predictors of complications after inguinal lymphadenopathy. Gynecol Oncol. 2001;82:329–32.PubMedCrossRefGoogle Scholar
  14. 14.
    Safdar A, Rolston KV. Stenotrophomonas maltophilia: changing spectrum of a serious bacterial pathogen in patients with cancer. Clin Infect Dis. 2007;45:1602–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Safdar A, Rodriguez GH, Balakrishnan M, et al. Changing trends in etiology of bacteremia in patients with cancer. Eur J Clin Microbiol Infect Dis. 2006;25:522–6.PubMedCrossRefGoogle Scholar
  16. 16.
    Han XY, Kamana M, Rolston KV. Viridans streptococci isolated by culture from blood of cancer patients: clinical and microbiologic analysis of 50 cases. J Clin Microbiol. 2006;44:160–5.PubMedCrossRefGoogle Scholar
  17. 17.
    Green JA, Kirwan JM, Tierney JF. Survival and recurrence after concomitant chemotherapy and radiotherapy for cancer of the uterine cervix. Lancet. 2001;385:781–6.CrossRefGoogle Scholar
  18. 18.
    Yessaian A, Magistris A, Burger RA, et al. Radical hysterectomy followed by tailored postoperative therapy in the treatment of stage 1B2 cervical cancer: feasibility and indications for adjuvant therapy. Gynecol Oncol. 2004;94:61–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Jurado M, Martinez-Monge R, Garcia-Foncillas J, et al. Pilot study of concurrent cisplatin, 5-fluorouracil, and external beam radiotherapy prior to radical surgery +/− intraoperative electron beam radiotherapy in locally advanced cervical cancer. Gynecol Oncol. 1999;74:30–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Micha JP, Goldstein BH, Rettenmaier MA, et al. Pelvic radiation necrosis and osteomyelitis following chemoradiation for advanced stage vulvar and cervical carcinoma. Gynecol Oncol. 2006;101:349–52.PubMedCrossRefGoogle Scholar
  21. 21.
    Anatoliotaki A, Valatas V, Mantadakis E, et al. Bloodstream infections in patients with solid tumors: associated factors, microbial spectrum and outcome. Infection. 2004;32:65–71.PubMedCrossRefGoogle Scholar
  22. 22.
    Elting LS, Rubenstein EB, Rolston KV, et al. Outcomes of bacteremia in patients with cancer and neutropenia: observations from two decades of epidemiological and clinical trials. Clin Infect Dis. 1997;25:247–59.PubMedCrossRefGoogle Scholar
  23. 23.
    Zahar JR, Farhat H, Chachaty E, et al. Incidence and clinical significance of anaerobic bacteremia in cancer patients: a 6-year retrospective study. Clin Microbiol Infect. 2005;11:724–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Fainstein V, Elting LS, Bodey GP. Bacteremia caused by non-sporulating anaerobes in cancer patients – a 12-year experience. Medicine (Baltimore). 1989;68:151–62.Google Scholar
  25. 25.
    Wynne JW, Armstrong D. Clostridial septicemia. Cancer. 1972;29:215–21.PubMedCrossRefGoogle Scholar
  26. 26.
    Safdar A. Strategies to enhance immune function in hematopoietic transplantation recipients who have fungal infections. Bone Marrow Transplant. 2006;38:327–37.PubMedCrossRefGoogle Scholar
  27. 27.
    Raad I, Hachem R, Hanna H, et al. Sources and outcome of bloodstream infections in cancer patients: the role of central venous catheters. Eur J Clin Microbiol Infect Dis. 2007;26:549–56.PubMedCrossRefGoogle Scholar
  28. 28.
    Raad I, Hanna H, Jiang Y, et al. Comparative activities of daptomycin, linezolid, and tigecycline against catheter-related methicillin-resistant Staphylococcus bacteremic isolates embedded in biofilm. Antimicrob Agents Chemother. 2007;51:1656–60.CrossRefGoogle Scholar
  29. 29.
    Strecker EP, Heber R, Boos I, et al. Preliminary experience with locoregional intraarterial chemotherapy of uterine cervical or endometrial cancer using the peripheral implantable port system (PIPS): a feasibility study. Cardiovasc Intervent Radiol. 2003;26:118–22.PubMedCrossRefGoogle Scholar
  30. 30.
    Sakuragi N, Nakajima A, Nomura E, et al. Complications related to intraperitoneal administration of cisplatin or carboplatin for ovarian carcinoma. Gynecol Oncol. 2000;79:420–3.PubMedCrossRefGoogle Scholar
  31. 31.
    Roybal JJ, Feliberti EC, Rouse L, et al. Pump removal in infected patients with hepatic chemotherapy pumps: when is it necessary? Am Surg. 2006;72:880–4.PubMedGoogle Scholar
  32. 32.
    Prasad KN, Pradhan S, Datta NR. Urinary tract infection in patients of gynecological malignancies undergoing external pelvic radiotherapy. Gynecol Oncol. 1995;57:380–2.PubMedCrossRefGoogle Scholar
  33. 33.
    Roos EJ, Van Eijkeren MA, Boon TA, et al. Pelvic exenteration as treatment of recurrent or advanced gynecologic and urologic cancer. Int J Gynecol Cancer. 2005;15:624–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Velasco E, Thuler LC, Martins CA, et al. Risk factors for infectious complications after abdominal surgery for malignant disease. Am J Infect Control. 1996;24:1–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Brooker DC, Savage JE, Twiggs LB, et al. Infectious morbidity in gynecologic cancer. Am J Obstet Gynecol. 1987;156:513–20.PubMedGoogle Scholar
  36. 36.
    Morgan LS, Daly JW, Monif GR. Infectious morbidity associated with pelvic exenteration. Gynecol Oncol. 1980;10:318–28.PubMedCrossRefGoogle Scholar
  37. 37.
    Ledger WJ, Gee C, Lewis WP. Guidelines for antibiotic prophylaxis in gynecology. Am J Obstet Gynecol. 1975;121:1038–45.PubMedGoogle Scholar
  38. 38.
    Hemsell DL, Johnson ER, Hemsell PG, et al. Cefazolin is inferior to cefotetan as single-dose prophylaxis for women undergoing elective total abdominal hysterectomy. Clin Infect Dis. 1995;20:677–84.PubMedCrossRefGoogle Scholar
  39. 39.
    Hemsell DL, Bernstein SG, Bawdon RE, et al. Preventing major operative site infection after radical abdominal hysterectomy and pelvic lymphadenectomy. Gynecol Oncol. 1989;35:55–60.PubMedCrossRefGoogle Scholar
  40. 40.
    Orr Jr JW, Shingleton HM, Hatch KD, et al. Correlation of perioperative morbidity and conization to radical hysterectomy interval. Obstet Gynecol. 1982;59:726–31.PubMedGoogle Scholar
  41. 41.
    Berkeley AS, Orr JW, Cavanagh D, et al. Comparative effectiveness and safety of cefotetan and cefoxitin as prophylactic agents in patients undergoing abdominal or vaginal hysterectomy. Am J Surg. 1988;155:81–5.PubMedCrossRefGoogle Scholar
  42. 42.
    Mann Jr WJ, Orr JW, Shingleton HM, et al. Perioperative influences on infectious morbidity in radical hysterectomy. Gynecol Oncol. 1981;11:207–12.PubMedCrossRefGoogle Scholar
  43. 43.
    Gussman D, Riva J, Carlson Jr JA. Prophylaxis for radical hysterectomy. Infect Surg. 1987;6:55.Google Scholar
  44. 44.
    Rosenshein NB, Ruth JC, Villar J, et al. A prospective randomized study of doxycycline as a prophylactic antibiotic in patients undergoing radical hysterectomy. Gynecol Oncol. 1983;15:201–6.PubMedCrossRefGoogle Scholar
  45. 45.
    Marsden DE, Cavanagh D, Wisniewski BJ, et al. Factors affecting the incidence of infectious morbidity after radical hysterectomy. Am J Obstet Gynecol. 1985;152:817–21.PubMedGoogle Scholar
  46. 46.
    Sevin BU, Ramos R, Lichtinger M, et al. Antibiotic prevention of infections complicating radical abdominal hysterectomy. Obstet Gynecol. 1984;64:539–45.PubMedGoogle Scholar
  47. 47.
    Micha JP, Kucera PR, Birkett JP, et al. Prophylactic mezlocillin in radical hysterectomy. Obstet Gynecol. 1987;69:251–4.PubMedGoogle Scholar
  48. 48.
    Sevin BU, Ramos R, Gerhardt RT, et al. Comparative efficacy of short-term versus long-term cefoxitin prophylaxis against postoperative infection after radical hysterectomy: a prospective study. Obstet Gynecol. 1991;77:729–34.PubMedGoogle Scholar
  49. 49.
    Shapiro M, Schoenbaum SC, Tager IB, et al. Benefit-cost analysis of antimicrobial prophylaxis in abdominal and vaginal hysterectomy. JAMA. 1983;249:1290–4.PubMedCrossRefGoogle Scholar
  50. 50.
    van Lindert AC, Giltaij AR, Derksen MD, et al. Single-dose prophylaxis with broad-spectrum penicillins (piperacillin and mezlocillin) in gynecologic oncological surgery, with observation on serum and tissue concentrations. Eur J Obstet Gynecol Reprod Biol. 1990;36:137–45.PubMedCrossRefGoogle Scholar
  51. 51.
    Shapiro M, Munoz A, Tager IB, et al. Risk factors for infection at the operative site after abdominal or vaginal hysterectomy. N Engl J Med. 1982;307:1661–6.PubMedCrossRefGoogle Scholar
  52. 52.
    Contant CM, Hop WC, van’t Sant HP, et al. Mechanical bowel preparation for elective colorectal surgery: a multicenter randomized trial. Lancet. 2008;370:2112–7.CrossRefGoogle Scholar
  53. 53.
    Braverman J, Adachi A, Lev-Gur M, et al. Spontaneous clostridia gas gangrene of uterus associated with endometrial malignancy. Am J Obstet Gynecol. 1987;156:1205–7.PubMedGoogle Scholar
  54. 54.
    Douvier S, Nabholtz JM, Friedman S, et al. Infectious pneumoperitoneum as an uncommon presentation of endometrial carcinoma: report of two cases. Gynecol Oncol. 1989;33:392–4.PubMedCrossRefGoogle Scholar
  55. 55.
    Weinstein WM, Onderdonk AB, Bartlett JG, et al. Experimental intra-abdominal abscesses in rats: development of an experimental model. Infect Immun. 1974;10:1250–5.PubMedGoogle Scholar
  56. 56.
    Henderson W. Synergistic bacterial gangrene abdominal hysterectomy. Obstet Gynecol. 1977;49:24S.Google Scholar
  57. 57.
    Bouma J, Dankert J. Recurrent acute leg cellulitis in patients after radical vulvectomy. Gynecol Oncol. 1988;29:50–7.PubMedCrossRefGoogle Scholar
  58. 58.
    Hunt TK, Rabkin J, von Smitten K. Effects of edema and anemia on wound healing and infection. Curr Stud Hematol Blood Transfus. 1986;53:101–13.PubMedGoogle Scholar
  59. 59.
    Bahary CM, Joel-Cohen SJ, Neri A. Necrotizing fasciitis. Obstet Gynecol. 1977;50:633–7.PubMedGoogle Scholar
  60. 60.
    Wilson B. Necrotizing fascitits. Am Surg. 1952;18:416.PubMedGoogle Scholar
  61. 61.
    Husseinzadeh N et al. Spontaneous occurrence of synergistic bacterial gangrene following external pelvic irradiation. Obstet Gynecol. 1984;63:859–62.PubMedGoogle Scholar
  62. 62.
    Hoffman MS, Turnquist D. Necrotizing fasciitis of the vulva during chemotherapy. Obstet Gynecol. 1989;74:483–4.PubMedGoogle Scholar
  63. 63.
    Roberts D. Necrotizing fasciitis of the vulva. Am J Obstet Gynecol. 1987;157:568.PubMedGoogle Scholar
  64. 64.
    Fisher JR, Conway MJ, Takeshita RT, et al. Necrotizing fasciitis. Importance of roentgenographic studies for soft-tissue gas. JAMA. 1979;241:803–6.PubMedCrossRefGoogle Scholar
  65. 65.
    Altmeier WA. Gas gangrene. Surg Gynecol Obstet. 1947;84:504.Google Scholar
  66. 66.
    Pelletier JP, Plumbley JA, Rouse EA, Cina SJ. The role of Clostridium septicum in paraneoplastic sepsis. Arch Pathol Lab Med. 2000;124:353–6.PubMedGoogle Scholar
  67. 67.
    McNeeley Jr SG, Hopkins MP, Ehlerova B, et al. Infection on a gynecologic oncology service. Gynecol Oncol. 1990;37:183–7.PubMedCrossRefGoogle Scholar
  68. 68.
    Miller C. Ligation or excision of the pelvic veins in the treatment of puerperal pyaemia. Surg Gynecol Obstet. 1917;25:431.Google Scholar
  69. 69.
    Twickler DM et al. Imaging of puerperal septic thrombophlebitis: prospective comparison of MR imaging, CT, and sonography. AJR Am J Roentgenol. 1997;169:1039–43.PubMedCrossRefGoogle Scholar
  70. 70.
    Zerhouni EA, Barth KH, Siegelman SS. Demonstration of venous thrombosis by computed tomography. AJR Am J Roentgenol. 1980;134:753–8.PubMedCrossRefGoogle Scholar
  71. 71.
    Schulman H, Zatuchni G. Pelvic thrombophlebitis in the puerperal and postoperative gynecology patient. Obscure fever as an indication for anticoagulant therapy. Am J Obstet Gynecol. 1964;90:1293.PubMedGoogle Scholar
  72. 72.
    Twickler DM, Setiawan AT, Evans RS, et al. Imaging of puerperal septic thrombophlebitis: prospective comparison of MR imaging, CT, and sonography. AJR Am J Roentgenol. 1997;169:1039–43.PubMedCrossRefGoogle Scholar
  73. 73.
    Josey WE, Staggers Jr SR. Heparin therapy in septic pelvic thrombophlebitis: a study of 46 cases. Am J Obstet Gynecol. 1974;120:228–33.PubMedGoogle Scholar
  74. 74.
    Brown CE, Stettler RW, Twickler D, et al. Puerperal septic pelvic thrombophlebitis: incidence and response to heparin therapy. Am J Obstet Gynecol. 1999;181:143–8.PubMedCrossRefGoogle Scholar
  75. 75.
    Lee AY et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med. 2003;349:146–53.PubMedCrossRefGoogle Scholar
  76. 76.
    Ruokonen E et al. Procalcitonin and neopterin as indicators of infection in critically ill patients. Acta Anaesthesiol Scand. 2002;46:398–404.PubMedCrossRefGoogle Scholar
  77. 77.
    Hirschmann JV. Fever of unknown origin in adults. Clin Infect Dis. 1997;24:291–300. Quiz 301–2.PubMedCrossRefGoogle Scholar

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© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Department of Infectious Diseases, Infection Control, and Employee HealthThe University of Texas M.D. Anderson Cancer CenterHoustonUSA

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