Predictive factors of septic shock and mortality in neutropenic patients

Abstract

Neutropenia is a major risk factor for developing a serious infection. Bacteremia still causes significant mortality among neutropenic patients with cancer. The purpose of this study was to identify risk factors for septic shock and for mortality in neutropenic patients with leukemia and bacteremia. Consecutive samples from 20 patients with acute myeloid leukemia and bacteremia were studied during a 1 year period (January-December 2003). All patients received empirical antibiotic therapies for febrile episodes using ceftazidime plus amikacin. About 110 neutropenic febrile episodes were noted: clinically documented 14.54%, microbiologically documented 16.36% and fever of unknown origin 69.09%. Gram-negative organism caused eight febrile episodes: Pseudomonas (5), Klebsiella (3). Gram-positive organism caused 10 episodes: Staphylococcus (6), Streptococci (2), Enterococci (2). Pulmonary infection accounted for 25% of clinically documented infections. About 14 of the 110 febrile episodes were associated with septic shock causing mortality in 7 patients. In a univariate analysis variables associated with septic shock were: pulmonary infection (OR = 17, p = 0.001), serum bicarbonate < 17 mmol/l (OR = 68, p < 0.001) and serum lactate >3 mmol/l (OR = 62, p < 0.001). Variables associated with mortality were: pulmonary infection (OR = 83, p < 0.001) and serum bicarbonate < 17 mmol/l (OR = 61, p < 0.001). In a multivariate analysis two variables were associated with septic shock: pulmonary infection (OR = 5, p = 0.043) and serum lactate >3 mmol/l (OR = 10, p = 0.003). An elevated serum lactate (>3 mmol/l) and low serum bicarbonate ( < 17 mmol/l) at the onset of bacteremia are useful biomarkers in predicting septic shock and mortality in neutropenic patients.

Early warning and prevention of pneumonia in acute leukemia by patient education, spirometry, and positive expiratory pressure: A randomized controlled trial

“…The prevalence was in range with previous reports 8, 33. Similar to other studies using AP 31, microbial findings from bronchial alveolar lavage and sputum in general were sparse and dominated by yeasts alone or coagulase negative staphylococci of unknown pathogenic significance. The most likely explanations for the lack of relevant pathogens are use of AP during severe neutropenia and the early shift to broad spectrum empiric antibiotic treatment upon onset of airway symptoms in combination with culture based methods.…”

“…Pneumonia remains a major challenge in acute leukemia treatment 5, 8, 9, 30 with a substantial mortality 27, 31. Prospective reports have demonstrated the feasibility and safety of outpatient management and early discharge of acute leukemia by inclusion of broad‐spectrum AP 11, 12, 17, 18, 20.…”

Elevation in serum lactate at the time of Febrile Neutropenia (FN) in hemodynamically-stable patients with Hematologic Malignancies (HM) is associated with the development of septic shock within 48 hours

“…serum lactate and septic shock in 20 AML subjects with known bacteremia. 28 Our study expands the clinical utility of lactate measurement by demonstrating an association between elevated lactate and the subsequent development of septic shock in a previously unstudied patient population: hemodynamically-stable, hematologic malignancy patients with febrile neutropenia. Importantly, lactate elevation preceded the onset of septic shock by up to 48 h (mean 26 h) supporting our conclusion that serum lactate could provide clinicians with an early warning to institute more intensive monitoring or could serve as a marker to guide resuscitation strategies in the context of a clinical trial.…”

Pulmonary infiltrates in patients with malignancies: why and how neutropenia influences clinical reasoning

“…In a recent cohort of 326 adult patients undergoing autologous stem cell transplantation, the risk of pneumonia was higher in patients who had myeloma or severe neutropenia for .7 days [14]. In addition, pneumonia is associated with an increased risk for septic shock and mortality [15]. In allogeneic stem cell transplantation, pulmonary complications are the events associated with the highest fatality rates, and pneumonia risk is highest after unrelated donor allogeneic peripheral blood stem cell transplantation [16].…”