FEVER IN THE NEUTROPENIC HOST - 11/09/11
Résumé |
Who hesitate and falter life away,
And lose tomorrow the ground won today.
MATTHEW ARNOLD
The Scholar Gypsy, 1853
Neutropenia is the major risk factor for serious bacterial and fungal infections in cancer patients following myelosuppressive chemotherapy.9, 81 Despite the progress made in supportive care of febrile neutropenic patients, including broad-spectrum antimicrobial agents and hematopoietic growth factors, neutropenia remains the major reason for hospitalization during or after chemotherapy.81 It is also a significant risk factor for infection in organ and marrow transplantation and for patients with bone-marrow failure.
The timely use of antibacterial agents, initiated at the first sign of fever in the neutropenic cancer patient, has dramatically reduced infection-related morbidity and mortality.72, 95 Despite appropriate interventions, 5% to 10% of cancer patients still succumb to infectious complications associated with neutropenia.25, 36, 82 Although most deaths now occur in patients with prolonged neutropenia, the risk of complications is high if antimicrobial therapy is delayed. Therefore, it is important to consider the febrile neutropenic patient as a medical emergency requiring immediate diagnostic and therapeutic interventions. Even in febrile neutropenic patients with a noncancer underlying condition the urgency of evaluation and treatment cannot be overstated. Although uncommon, neutropenic patients can have a serious infection in the absence of fever.84, 97 Thus, signs or symptoms compatible with infection in the neutropenic patient, regardless of the presence of fever, warrant prompt attention.
The importance of an adequate number of functioning neutrophils in antimicrobial activity has been appreciated for many years. At the turn of the century, Metchnikoff noted that the absence of what we now know as granulocytes could result in failure to control infections. Prior to the use of myelosuppressive chemotherapy, rare patients with congenital agranulocytosis or an acquired neutropenia were noted to suffer recurrent bacterial infections, especially of the skin and sinopulmonary tract. Similarly, bone marrow–failure patients frequently succumbed to bacterial or fungal infections, often despite intervention with antimicrobial agents.108 In both of these populations, the predisposition to infection was ascribed to the absence of circulating neutrophils. The modern approach to the management of febrile neutropenic cancer patients has been successfully applied to these and other populations, including solid organ–transplant recipients, patients with acquired or intrinsic neutropenia, and HIV-infected individuals. Other factors contributing to the overall state of immunosuppression, however, are important determinants of infectious risk. In this regard, not all patients with neutropenia are identical.
This article addresses the foundations for the evolution of empiric therapy in the febrile neutropenic cancer patient, attempts to clarify how and in what way these principles can be adapted to different neutropenic hosts, and addresses the problems associated with neutropenia that result from a serious infection.
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| Address reprint requests to Stephen J. Chanock, MD, National Cancer Institute, Bldg. 10, Rm. 13N240, Bethesda, Maryland 20892 |
Vol 10 - N° 4
P. 777-796 - décembre 1996 Retour au numéro
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- FALCIPARUM MALARIA
- Gerald S. Murphy, Edward C. Oldfield
- ACUTE BACTERIAL MENINGITIS
- John Segreti, Alan A. Harris
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