|Year : 2014 | Volume
| Issue : 4 | Page : 447-449
Pattern of bloodstream infections in patients with hematological malignancies in a tertiary care centre
S Bansal1, SH Advani2
1 Department of Pediatric Oncology, Asian Insititute of Oncology, SL Raheja Hospital, Mahim, Mumbai, Maharashtra, India
2 Department of Medical Oncology, Asian Insititute of Oncology, SL Raheja Hospital, Mahim, Mumbai, Maharashtra, India
|Date of Web Publication||1-Feb-2016|
Department of Pediatric Oncology, Asian Insititute of Oncology, SL Raheja Hospital, Mahim, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The purpose of our study was to evaluate the clinical characteristics, to understand the pattern of bloodstream infections (BSIs), and to determine the risk factors contributing to high-risk febrile neutropenia in patients with hematological malignancy. Materials And Methods: A comprehensive review of retrospective data was done from 2004 till 2012 from a single center. Results: There were total 171 consecutive febrile episodes with 103 acute lymphoblastic leukemia (ALL) patients and 63 acute myeloid leukemia (AML) patients. The highest number of febrile neutropenia episodes occurred during ALL and AML induction followed by consolidation treatment with high-dose cytarabine. In our study population, the most common organisms isolated were Gram-positive (20%) followed by Gram-negative (6.4%) organisms. The incidence of fungal sepsis was only 3%. In our study, it was seen that the recovery from febrile neutropenia depends upon the disease, ALL recovered rapidly compared to AML (P < 0.001) and also the on the phase of treatment, i.e consolidation recovered earlier than induction (P < 0.001). There was no death recorded in this study population during febrile neutropenia. Conclusions: The incidence of febrile neutropenia depends upon the type of haematological malignancy and the aggressiveness of therapy required treating the disease especially during induction. The improvement in antimicrobial coverage and its prompt use leads to the selective growth of Gram-positive organisms.
Keywords: Bloodstream infections, febrile neutropenia, Hematological malignanicies
|How to cite this article:|
Bansal S, Advani S H. Pattern of bloodstream infections in patients with hematological malignancies in a tertiary care centre. Indian J Cancer 2014;51:447-9
| » Introduction|| |
Febrile neutropenia is a major complication of anticancer therapy leading to unavoidable morbidity and mortality ranging from 5 to 48% depending on the organism and degree of neutropenia., It is a limiting factor during the intensive treatment of hematological malignancies, and clinicians have to weigh the benefits and risks of anticancer therapy taking into account febrile neutropenia while treating a patient on a regular basis. Hence, it becomes increasingly important to understand the various factors responsible for febrile neutropenia in one's patient population.
The purpose of our study was to evaluate the clinical characteristics, to understand the pattern of bloodstream infections (BSIs), and to determine the risk factors contributing to high-risk febrile neutropenia in hematological malignancies of patients.
| » Material and Methods|| |
A comprehensive review of retrospective data from 2004 till 2012 from a single center was done. The case records of the patients of all ages with febrile episodes were reviewed. Patients with hematological malignancy having fever and an absolute neutrophil count (ANC) <500 or which was expected to drop in the next 48 hours [defined as per the febrile neutropenia guidelines of the Infectious Diseases Society of America (IDSA)], were enrolled in the study. Data was collected from the case files and computerized summaries of patients. Information regarding clinical characteristics of the patient, type of hematological malignancy, phase of treatment, ANC at the time of febrile neutropenia, bloodstream isolates, duration of febrile neutropenia, its sensitivity pattern, and antibiotic usage were recorded. Bloodstream samples were collected from peripheral blood, central venous catheters, and peripheral venous catheters in case patients had them. A detailed review of the microbiological data and radiological and other relevant investigations available at the time of febrile neutropenia was done. Blood culture was performed on automated system BacTAlert ® 3D. Before the start of antibiotics, blood was collected in sterile manner in a culture media provided by BioMériux company. The sample was sent for aerobic and fungal cultures and where suspected anerobic cultures were also added. The choice of antibiotic disks used was determined by the guidelines of the Clinical and Laboratory Standards Institute (CLSI).
First-line antibiotics included a combination of piperacillin/tazobactam with amikacin. Second-line antibiotics included carbapenems, and third-line antibiotics were colistin or depended upon the sensitivity pattern of the organism. For antifungals, voriconazole was used as first line and in the probable or proven cases of aspergillosis infections. For Candida infections, amphotericin B was used and was also used as second-line antifungal. The removal of central catheter or peripheral catheter was done in cases of isolation of organisms such as Candida and Pseudomonas.
SPSS 17 software system was used to analyze the data. Febrile episodes were analyzed for status of disease, that is, in remission, induction, or relapse at the time of febrile neutropenia and effect of ANC on duration of fever, change in line of antibiotics, and use of antifungals. Chi-square test was used to compare the different groups.
| » Results|| |
There were 171 consecutive febrile episodes recorded from year 2004 till 2012. The baseline characteristics are given in [Table 1] as below:
|Table 1: Baseline clinical characteristics of patients with febrile episodes|
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|Table 2: Frequency and type of organisms isolated from the blood stream during febrile neutropenia episodes|
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Antibiotic and antifungal usage
Ninety-two episodes were treated with first-line intravenous (IV) antibiotics and 75 febrile neutropenic episodes required change to second-line line antibiotics, whereas only four episodes required additional third-line IV antibiotics. Regarding antifungals, 55 (32.2%) patients were treated with first-line antifungals, 6 (5.5%) required second-line antifungals, and almost 110 febrile episodes did not require any antifungals during their neutropenic episodes.
| » Discussion|| |
The primary aim of this study was to understand the pattern of BSI infections in patients with febrile neutropenia undergoing treatment for hematological malignancies. The reported incidence of BSI in the literature ranges from 11 to 38%; in our study, it was 27%., We found that the frequency of Gram-positive organisms was more, which is consistent with the reported western data. However, it was contrary to the reported data from India. This difference could be explained by the increased use of central lines in our setup; however, we did not use any prophylactic antibiotics in our patient population. Regarding antibiotic usage, a few isolates including Acinetobacter and extended-spectrum b-lactamase Klebsiella were resistant to carbapenems, but the incidence of both were low and majority of the patients were managed by first-line antibiotics. Similarly, the incidence of fungal infections was also quite low and almost 65% of the patients with febrile neutropenia did not even require empirical antifungals. However, this is a retrospective study and has its limitations and more careful collection of data is required to record all the relevant information.
| » Conclusion|| |
In our study, we concluded the following points: The ANC and gender at the time of febrile neutropenia are not significant in determining the recovery and outcome of the patient. The most important factors on multivariate analysis were type of disease, that is, ALL patients recover faster than AML patients (P < 0.001), and as expected, postinduction febrile neutropenia recovers earlier than induction febrile neutropenia irrespective of the type of hematological malignancy (P < 0.001). Another important conclusion was that younger patients recover faster than older patients (P = 0.038).
| » References|| |
Wisplinghoff H, Seifert H, Wenzel RP, Edmond MB. Current trends in the epidemiology of nosocomial bloodstream infections in patients with hematological malignancies and solid neoplasms in hospitals in the United States. Clin Infect Dis 2003;36:1103-10.
de Naurois J, Novitzky-Basso I, Gill MJ, Marti FM, Cullen MH, Roila F; ESMO Guidelines Working Group. Management of febrile neutropenia: ESMO Clinical Practice Guidelines. Ann Oncol 2010;21(Suppl 5):v252-6.
Hughes WT, Armstrong D, Bodey GP, Bow EJ, Brown AE, Calandra T, et al. 2002 Guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2002;34:730-51.
De Pauw B, Verveij PE. Infections in patients with hematologic malignancies. In: Mandell GL, Bennett JE, Doolin R, editors. Principles and practice of infectious diseases. Philadelphia: Churchill Livingstone; 2005. p. 3432-41.
Clinical and Laboratory Standards Institute; 2008 Performance standards for antimicrobial susceptibility testing; Eighteenth informational supplement. M100-S18. Wayne, PA: Clinical and Laboratory Standards Institute (CLSI); 2008.
Madani TA. Clinical infections and bloodstream isolates associated with fever in patients undergoing chemotherapy for acute myeloid leukemia. Infection 2000;28:367-73.
Gaytαn-Martνnez J, Mateos-Garcνa E, Sαnchez-Cortιs E, Gonzαlez-Llaven J, Casanova-Cardiel LJ, et al. Microbiological findings in febrile neutropenia. Arch Med Res 2000;31:388-92.
Prabhash K, Medhekar A, Ghadyalpatil N, Noronha V, Biswas S, et al. Blood stream infections in cancer patients: A single centre experience of isolates and sensitivity pattern. Indian J Cancer 2010;47:184-8.
[Table 1], [Table 2], [Table 3]
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