Bloodstream infections in patients with hematological malignancies: which is more fatal – cancer or resistant pathogens?

Abstract

BackgroundThe primary objective of this study was to report the incidence of bloodstream infections (BSIs) and clinically or microbiologically proven bacterial or fungal BSIs during neutropenic episodes in patients with hematological malignancies.MethodsIn this retrospective observational study, all patients in the hematology department older than 14 years who developed febrile neutropenia during chemotherapy for hematological cancers were evaluated. Patients were included if they had experienced at least one neutropenic episode between November 2010 and November 2012 due to chemotherapy in the hematology ward.ResultsDuring 282 febrile episodes in 126 patients, 66 (23%) episodes of bacteremia and 24 (8%) episodes of fungemia were recorded in 48 (38%) and 18 (14%) patients, respectively. Gram-negative bacteria caused 74% (n=49) of all bacteremic episodes. Carbapenem-resistant Gram-negative bacteria (n=6) caused 12% and 9% of Gram-negative bacteremia episodes and all bacteremia episodes, respectively. Carbapenem-resistant Gram-negative bacteria included Acinetobacter baumannii (n=4), Pseudomonas aeruginosa (n=1), and Serratia marcescens (n=1). Culture-proven invasive fungal infection occurred in 24 episodes in 18 cases during the study period, with 15 episodes in ten cases occurring in the first study year and nine episodes in eight cases in the second study year. In 13 of 18 cases (72%) with bloodstream yeast infections, previous azole exposure was recorded. Candida parapsilosis, C. glabrata, and C. albicans isolates were resistant to voriconazole and fluconazole.ConclusionBSIs that occur during febrile neutropenic episodes in hematology patients due to Gram-negative bacteria should be treated initially with non-carbapenem-based antipseudomonal therapy taking into consideration antimicrobial stewardship. Non-azole antifungal drugs, including caspofungin and liposomal amphotericin B, should be preferred as empirical antifungal therapy in the events of possible or probable invasive fungal infections with an absence of pulmonary findings due to increase azole resistance.

Bloodstream infections in neutropenic cancer patients: A practical update

“…54 Also another small study from Turkey demonstrated a fatality rate of 50% for carbapenem-resistant GN in neutropenic patients. 34 Finally, the mortality rate was also found to be increased in polymicrobial BSIs compared to monomicrobial infections (19% vs. 12%; pD 0.07). 43 …”

“…29 However, this tendency has reversed again, with GN bacteria becoming more frequent than GP in many centers. [32][33][34][35][36][37][38] According to a questionnaire survey performed among hematology centers from Europe and Israel participating in the European Conference on Infections in Leukemia (ECIL) in 2011, Enterobacteriaceae were isolated in approximately 30% (range 8-56%) of the BSIs, followed by coagulase-negative staphylococci (24%, range 7-51%). 39 The GP to GN ratio was 55% to 45%, but a large variability between hospitals and countries has been noted.…”

“…54 In a monocentric retrospective observational trial performed in Turkey, carbapenemresistant GN were isolated in 9% of all the bacteremic episodes during neutropenia. 34 Of note, rectal colonization by carbapenem-resistant K. pneumoniae was followed by BSIs in 45% of neutropenic patients. 55 Also non-fermenting GN rods harbor frequently this type of resistance.…”

Global prevalence of carbapenem resistance in neutropenic patients and association with mortality and carbapenem use: systematic review and meta-analysis

“…Neutropenia was defined by the majority of studies as an absolute neutrophil count (ANC) below 500/mm 3 . Eight studies reported neutropenia as ANC <1000/mm 3 (with predicted decrease below 500 within 48-72 h), 14,[17][18][19][20] and two studies as ANC <1000/mm 3 .…”

“…11,14,16,19,27,29,35,36,39 Haematological malignancies represented the main cause of neutropenia; seven studies included also patients with solid cancer (ranging from 5% to 44% of the patient population). Acute leukaemia was the most common haematological disease in 17 (57%) studies.…”