Febril Nötropenik Ataklarda Kan Kültüründe Üreyen Bakteriler Mutlaka Kombine Tedavi Gerektiriyor Mu?

Year 2021, Volume: 13 Issue: 1, 5 - 12, 30.04.2021

Selçuk Aksöz , Halit Özsüt

https://doi.org/10.35514/mtd.2021.40

Abstract

Giriş
İnfeksiyonlar nötropenik hastalardaki en önemli morbidite ve mortalite nedenidir. Kan kültürleri de nötropenik hastalarda infeksiyon etkenlerini belirlemek ve her hastanenin belirlenen bu etkenlere göre febril nötropenik hastaların ampirik tedavisinde seçilecek antibiyotikleri seçmesinde en önemli materyaldir.
Gereç ve Yöntem
Bu çalışmada 1 Haziran 2005 - 1 Ağustos 2007 tarihleri arasında bir üniversite hastanesi hematoloji biriminde yatan febril nötropenik hastaların kan kültürlerindeki üremeler ve üreyen etkenlerin duyarlılıkları incelendi.
Bulgular
Çalışma süresi boyunca 50 hastada 61 nötropeni atağı incelendi ve toplam 72 bakteri izole edildi. Bu bakterilerin %69’u Gram-negatif çomak, %31 i Gram-pozitif olarak tespit edildi. Kan kültüründe üreyen bakteriler arasında E.coli en sık (n=31,%43) görülen etkendi. Daha sonra azalan sıklıkta Enterobacter spp (n=8,%11),K.pneumoniae (n=6,%8),Enterococcus spp (n=6,%8),MSSA(n=6,%8),MRKNS (n=5,%7),MSKNS (n=3,%4),MRSA (n=2,%3),Serratia marcescens (n=1,%1.4),P.aeruginosa (n=1,%1.4), Acinetobacter spp (n=1,%1.4), Salmonella spp (n=1,%1.4), K.oxytoca (n=1,%1.4) tespit edilmiştir. Bu bakterilerin duyarlılık paternleri incelendiğinde sırasıyla imipenem(%98),meropenem(%98),netilmisin(%84), sefoperazon-sulbaktam(%80), piperasilin-tazobaktam(%76), amikasin(%75), sefepim(%71), siprofloksasin(%57), seftazidim(%53)’ e duyarlı oldukları görüldü.
Bakteriyemiye neden olan hastalıklar incelendiğinde 19 hastada bakteriyemi kaynağı tespit edildi. Buna göre hastalarımızda en sık üriner sistem infeksiyonu(n=13,%68) olmak üzere, kateter infeksiyonu(n=3,%15) pnomoni(n=2,%10), yumuşak doku infeksiyonu(n=1,%5) saptandı.Çalışmamızda febril nötropenik hastalar için en önemli prognostik faktörler olarak MASCC skoru ve nötropeni süresi olduğu görülmüştür.

Keywords

febril nötropeni, monoterapi, kombine tedavi

Do Bacteria Growing in Blood Culture in Febrile Neutropenic Attacks Necessarily Require Combined Treatment?

Abstract

Introduction
Infections are the most important cause of morbidity and mortality in neutropenic patients. Blood cultures are the most important material in determining the infectious agents in neutropenic patients and choosing the antibiotics to be selected in the empirical treatment of febrile neutropenic patients according to these factors.
Materials and Methods
In this study, the susceptibility of the growth and reproductive factors in the blood cultures of febrile neutropenic patients in the hematology unit of a university hospital between 1 June 2005 and 1 August 2007 were investigated.
Results
During the study period, 61 neutropenia attacks in 50 patients were examined and a total of 72 bacteria were isolated. Of these bacteria, 69% were Gram-negative rods and 31% were Gram-positive. E.coli was the most common (n = 31, 43%) among the bacteria growing in the blood culture. Then, with decreasing frequency, Enterobacter spp (n = 8, 11%), K.pneumoniae (n = 6, 8%), Enterococcus spp (n = 6, 8%), MSSA (n = 6, 8%), MRKNS ( n = 5, 7%), MSCNS (n = 3, 4%), MRSA (n = 2, 3%), Serratia marcescens (n = 1, 1.4%), P.aeruginosa (n = 1, 1.4%) Acinetobacter spp (n = 1, 1.4%), Salmonella spp (n = 1, 1.4%), K.oxytoca (n = 1, 1.4%). Imipenem (98%), meropenem (98%), netilmicin (84%), cefoperazone-sulbactam (80%), piperacillin-tazobactam (76%), amikacin (75%), cefepime (71%) ), ciprofloxacin (57%) and ceftazidime (53%).
When bacterial diseases were investigated, bacteremia was detected in 19 patients. Accordingly, the most common urinary tract infection in our patients (n = 13, 68%), catheter infection (n = 3, 15%) pnomoni (n = 2, 10%), soft tissue infection (n = 1, 5%) In our study, the most important prognostic factors for febrile neutropenic patients were MASCC score and duration of neutropenia.

Conclusion
When blood culture growths are considered (P.aeruginosa, Acinetobacter spp), because of the relatively rare occurrence of cases, high-risk conditions are considered considering adverse effects such as nephrotoxicity and ototoxicity due to aminoglycosides and increased treatment costs. It was concluded that the use of combined therapy other than MASCC score, length of the expected duration of neutropenia, had no superiority to monotherapy.

Keywords

Febrile Neutropenia, monotherapy, combined therapy

References

• Referans1. Meunier F. Infections in patients with acuteleukemia and lymphoma. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 4th ed. New York: Churchill Livingstone, 1995:2675-86.
• Referans2. Bodey GP. Managing Infections in theImmunocompromised Patient. ClinInfectDis 2005;40 (Suppl 4):239.
• Referans3. Ramphal R.Is monotherapyforfebrileneutropeniastill a viablealternative?ClinInfectDis 1999;29:508-14.
• Referans4. ClinicalandLaboratoryStandardsInstitute/CLSI. PerformanceStandardsforAntimicrobial Disk SusceptibilityTests; ApprovedStandard-Eight Edition. CLSI/NCCLS document M2-A8. ClinicalandLobaratoryStandardInstitude, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania, 2005.
• Referans5. ClinicalandLaboratoryStandardsInstitute/CLSI. PerformanceStandardsforantimicrobialSusceptibilityTesting; fifteenthInformationalSupplement. CLSI/NCCLS document M100-S15 (ISBN 1-56238-556-9). ClinicalandLaboratoryStandardsInstitute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania, 2005.
• Referans6. FebrilNötropeni Çalışma Grubu. FebrilNötropenik Hastalarda Tanı Ve Tedavi Klavuzu. Flora 2004;9(1):5-28.
• Referans7. Akova M. Febrilnötropenik hastalarda infeksiyon etkeni olarak Gram-negatif bakterilerin dönüşü. In: 4. FebrilNötropeniSimpozyumu (22-25 Şubat 2001,Antalya)Kitabı. Antalya: FebrilNötropeni Grubu, 2001:O-13
• Referans8. Pizzo PA, Hathorn JW, Hiemenz J, Browne M, Commers J, Cotton D, Gress J, Longo D, Marshall D, McKnight J. A randomized trial comparing ceftazidimealonewithcombinationantibiotictherapy in cancerpatientswithfeverandneutropenia. N Engl J Med. 1986;315:552-8.
• Referans9. Aksu G,Ruhi MZ, Akan H, Bengisun S, Ustun C,Arslan O, Ozenci H. Aerobicbacteria land fungalinfections in peripheral bloodstemcelltransplants. Bone MarrowTransplant 2001;27:201-5
• Referans10. Jiang X, Zhang Z, Li M, Zhou D, Ruan F, and Lu Y Detection of extended-spectrum beta-lactamases in clinicalisolates of Pseudomonas aeruginosa. AntimicrobAgentsChemother 2006;50:2990–5.
• Referans11. Akova M, Akan H, Korten V, et al. Comparison of meropenem with amikacin plus ceftazidime in theempiricaltreatment of febrileneutropenia: a prospectiverandomisedmulticentretrial in patientswithoutpreviousprophylacticantibiotics. MeropenemStudyGroup of Turkey. Int J AntimicrobAgents 1999;13:15-9.
• Referans12. Çağatay AA, Punar M, Nalçacı M, Özsüt H, Eraksoy H, Atamer T, Dinçol G, Çalangu S. Hematolojik malignitesi olan hastalarda febrilnötropeni etkenleri. KlimikDerg 2001;14:7-9.
• Referans13. Alan S. FebrilNötropenik Hastalarda Ateş Nedenlerinin Araştırılması. Uzmanlık Tezi. İstanbul: İstanbul Üniversitesi İstanbul Tıp Fakültesi, 1997.
• Referans14. Bliziotis IA, Samonis G, Vardakas KZ, Chrysanthopoulou S, Falagas ME. Effect of aminoglycosideand beta-lactam combination therapy versus beta-lactammonotherapy on theemergence of antimicrobialresistance: a meta-analysis of randomized, controlledtrials. ClinInfectDis 2005;41:149-58.
• Referans15. Bouza E, Munoz P. Monoterapy versus combination therapy for bacteria linfections. MedClin North Am 2000;84:1357-89.
• Referans16. Walsh TJ, Newman KR, Moody M, Wharton RC, Wade JC. Trichosporonosis in patients with neoplastic disease. Medicine 1986;65:268-79.
• Referans17. Pizzo PA. Empirical therapy and prevention of infection in the immunocompromised host. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, andBennett’sPrinciplesandPractice of InfectiousDiseases. 6th ed. Philadelphia: Churchill Livingstone, 2005:3442-62.