Pulmonary infiltrations in febrile patients with neutropenia. Risk factors and outcome under empirical antimicrobial therapy in a randomized multicenter study

Maschmeyer, Georg; Link, Hartmut; Hiddemann, Wolfgang; Meyer, Peter; Helmerking, M.; Eisenmann, Edith; Schmitt, Josef; Adam, Dieter

doi:10.1002/1097-0142(19940501)73:9<2296::aid-cncr2820730910>3.0.co;2-7

Cited by 123 publications

(64 citation statements)

References 69 publications

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“…Additionally, most neutropenic patients with pneumonia receive antifungal drugs according to international guidelines [16,18,19,26]. It is known that previous antimicrobial treatment lowers the yield of BAL culture and is probably responsible for the low impact on treatment changes [4,5,7,9,30].…”

Section: Discussionmentioning

confidence: 99%

“…Among these infections, pneumonia is a very serious complication and has a poor prognosis, especially if treatment is delayed [10,11,31]. Patients with neutropenia should be treated immediately after onset of fever or any sign of infection and antimicrobial treatment should be initiated according to published guidelines even if positive diagnostic results are still lacking [13,16,18,19].…”

Section: Introductionmentioning

confidence: 99%

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Therapeutic implication of BAL in patients with neutropenia

Kuehnhardt

Hannemann²,

Schmidt³

et al. 2009

Ann Hematol

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Bronchoalveolar lavage (BAL) is a practicable procedure establishing the etiology of pneumonia. In patients with neutropenia, empirical antimicrobial treatment is mandatory immediately after diagnosis of infection, usually before results of BAL are available. We evaluated the impact of BAL on treatment and outcome of pneumonia in immunocompromised patients with a special regard to neutropenia. Bronchoscopy with BAL was performed in 58 episodes of clinical documented pneumonia in patients with hematological malignancies (88%) or solid tumors (12%), in 30 cases patients had neutropenia, in 28 cases patients had no neutropenia. In 93% of cases, BAL was performed under empirical antimicrobial treatment. BAL fluid was cultivated for bacteria, fungi, and tested for Pneumocystis jirovecii and cytomegalovirus (CMV). BAL revealed positive bacterial results in 67% of cases. Gram-positive microorganisms were detected in 95% of positive BAL results, gram-negative microorganisms in 23%, mixed bacterial cultures occurred in 41%. Positive fungi cultures were found in 59%. P. jirovecii was detected in 5% of cases tested and CMV in 8%. There was no significant difference between neutropenic and non-neutropenic patients. BAL results directed a change of therapy in only six of 58 episodes (5%). Overall mortality related to pneumonia was 16%. In this patient setting, the yield of BAL rarely has a significant influence on treatment and outcome of pneumonia. The early beginning of antimicrobial treatment reduces the diagnostic yield of BAL. In patients with pneumonia during neutropenia, its use should be well considered.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Therapeutic implication of BAL in patients with neutropenia

Kuehnhardt

Hannemann²,

Schmidt³

et al. 2009

Ann Hematol

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“…Kolbe et al 7 observed a 5% rate of pneumonia in PBSCT patients and Maschmeyer et al 8 showed a rate of pneumonia of around 20% in patients receiving conventional chemotherapy. In our study, pneumonia occurred in 24% of patients in the CCT group.…”

Section: Discussionmentioning

confidence: 99%

Febrile neutropenia in allogeneic and autologous peripheral blood stem cell transplantation and conventional chemotherapy for malignancies

Çelebi

Akan

Akçağlayan

et al. 2000

Bone Marrow Transplant

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Summary:The risk and outcome of infection in febrile neutropenic patients is mainly determined by the duration of neutropenia, the underlying disease or the treatment. This study was undertaken to compare infections and the outcome after conventional chemotherapy (CCT), allogeneic PBSC transplantation (alloPBSCT) or autologous PBSC transplantation (autoPBSCT), during the period of neutropenia, in a single center. A total of 145 patients (50 in CCT group, 50 in alloPBSCT and 45 in autoPBSCT) were evaluated. In the alloPBSCT group, 86% of the patients (43/50), in the autoPBSCT group 93% of the patients (42/45) and in the CCT group 92% (46/50) of the patients had at least one febrile episode during their neutropenic period (P Ͼ 0.05). Microbiologically and/or clinically documented infection rates were 50% (25/50), 42% (19/45) and 48% (24/50) respectively. Gram-positive pathogens, mostly coagulase-negative staphylococci were the most frequent cause of bacteremias in all groups. The frequency of CNS infections was significantly higher in the alloPBSCT and autoPBSCT groups compared to the CCT group (P Ͻ 0.008 and P Ͻ 0.04, respectively). Catheter infections were frequent in the PBSCT groups and pulmonary infections were more frequent in the CCT group (P Ͻ 0.05). The CCT group needed longer antibiotic usage compared to the alloPBSCT group (P Ͻ 0.006). The duration of neutropenia and the type of treatment given, does not affect the rate of febrile episodes, but affects the type of infections in febrile neutropenic patients. Bone Marrow Transplantation (2000) 26, 211-214. Keywords: febrile neutropenia; allogeneic peripheral blood stem cell transplantation; autologous peripheral blood stem cell transplantation; chemotherapy Infectious complications are associated with morbidity and mortality in patients with malignancies. Currently, this complication occurs more frequently and is related to the increased use of high-dose treatment modalities, and stem

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“…4 The application of EAT is indicated without delay in patients with severe sepsis or septic shock, or in those with signs of focal infection (pulmonary infiltrates, sinusitis, brain abscess, skin lesions and abdominal focus) in which IFI is an outstanding aetiology. [14][15][16][17][18][19][20][21] In those patients at high risk for fungal infection, when fever and neutropenia persists without an alternative diagnosis, EAT may be indicated through an individualized clinical decision. In the rest of the patients with asymptomatic fever who are clinically stable (which constituted the main clinical syndrome of PFN) with a low IFI incidence (null in our study), EAT would not be applied and further diagnostic evaluation, including high-resolution thorax scan, galactomannan and abdominal ultrasound, should be performed to establish the aetiology of the persistent fever.…”

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confidence: 99%

Empirical antifungal therapy in selected patients with persistent febrile neutropenia

Aguilar‐Guisado

Espigado

Cordero

et al. 2009

Bone Marrow Transplant

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Universal empirical antifungal therapy (EAT) in patients with unexplained persistent febrile neutropenia (PFN) is the standard of care, but EAT could be applied in selected patients on the basis of clinical criteria and risk factors. A prospective interventional study was carried out to analyse the incidence and related mortality of invasive fungal infection (IFI) in patients with PFN according to whether or not EAT was indicated. EAT was indicated according to the following criteria: (a) severe sepsis or septic shock; (b) focused infection: lung, central nervous system, sinus, abdominal or skin; (c) individualized clinical decision in patients at high risk. Sixty-six (19%) of 347 episodes of febrile neutropenia fulfilled PFN criteria, 97% with a haematological malignancy. Just 26 (39.4%) were treated with EAT. The overall IFI incidence was 4.5%. In the group that received EAT, three patients developed IFI (11.5%), in comparison with none in the group that did not receive it (P ¼ 0.04, RR 2.7:1.9-3.8). IFI-related mortality was null in the group that did not receive EAT and 8% (two of 26 patients) in the group that received EAT. These data suggest that in patients with PFN, EAT in selected patients may be safe and avoid unnecessary antifungal therapy.

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Pulmonary infiltrations in febrile patients with neutropenia. Risk factors and outcome under empirical antimicrobial therapy in a randomized multicenter study

Cited by 123 publications

References 69 publications

Therapeutic implication of BAL in patients with neutropenia

Therapeutic implication of BAL in patients with neutropenia

Febrile neutropenia in allogeneic and autologous peripheral blood stem cell transplantation and conventional chemotherapy for malignancies

Empirical antifungal therapy in selected patients with persistent febrile neutropenia

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