Febril nötropenik hastalarda orofarengeal enfeksiyonların irdelenmesi: 335 ataklık çalışma

Öz

Amaç Nötropenik hastalarda mukozit orofarenks başta olmak üzere tüm gastrointestinal sistemde oluşabilmektedir. Mukoza bütünlüğünün bozulması lokal invazyona zemin hazırlar ve önemli bir enfeksiyon odağı haline gelmesine neden olur. Bu çalışmada febril nötropenik hastalarda gelişen orofarengeal enfeksiyonların değerlendirilmesi ve oral kavite muayenesinin önemine dikkati çekmek amaçlanmıştır.

Yöntem Tersiyer bir hastanede üç yıl boyunca tanı alan hematolojik maligniteli febril nötropenik hastaların demografik verileri, atak sayısı, malignitelerin dağılımı ve gelişen orofarengeal enfeksiyonlar değerlendirildi.

Bulgular Toplam 335 atak geçiren 170 hasta çalışmaya dahil edildi. Mikrobiyolojik olarak dökümante edilen enfeksiyonlarda en sık bakteremi (n=92, %27.5) vardı. İkinci en sık enfeksiyon orofarengeal enfeksiyonlardı (n=69, %20.1).Orofarengeal enfeksiyonlardan en sık izole edilen mikroorganizma funguslardı (n=34, %49.3).

Sonuç Febril nötropenik hastaların orofarengeal enfeksiyonları lokalize ve sistemik enfeksiyona ilerleyen klinik tablolara neden olabilir. Hastaların oral kavitesinin günlük muayenesi, bakımı özenli bir şekilde yapılmalıdır. Orofarengeal floraları yakın takip edilmeli ve olası bir enfeksiyon tablosunun olduğu durumlarda buradaki floranın da kaynak olabileceği mutlaka göz önünde bulundurulmalıdır.

Anahtar Kelimeler

• febril nötropeni,orofaringeal infeksiyonlar

Evaluation of oropharyngeal infections in febrile neutropenic patients: a study of 335 episodes

Öz

Objective In neutropenic patients, mucositis can occur in the entire gastrointestinal tract, especially in the oropharynx. Disruption of mucosal integrity provides the basis for local invasion and causes it to become an important focus of infection. The aim of this study was to draw attention to the importance of oral cavity examination and evaluation of oropharyngeal infections in patients with febrile neutropenia (FN).

Methods Demographic data, number of episodes, distribution of malignancies and developing oropharyngeal infections of febrile neutropenic patients with hematologic malignancies in a tertiary hospital over a three-year period were evaluated.

Results A total of 170 patients with 335 FN episodes were included in our study. Bacteremia was the most common microbiologically documented infection (n=92, 27.5%). the second most common infection was oropharyngeal infections (n=69, 20.1%). The most common microorganism isolated from oropharyngeal infections was fungi (n=34, 49.3%).

Conclusions Oropharyngeal infections of febrile neutropenic patients may cause localized and systemic infections. Daily examination and care of the oral cavity of the patients should be done with care. The oropharyngeal flora should be closely monitored and it should be considered that the flora may also be a source in case of a possible infection.

Anahtar Kelimeler

• febrile neutropenia,oropharyngeal infections

Kaynakça

1. 1. Febril nötropenik hastalarda tanı ve tedavi kılavuzu.Flora 2004;9:5-28.
2. 2. Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of America. Clin Infect Dis 2011;15:52.
3. 3. Özsüt H. İmmünsupresif konakların değerlendirilmesi ve görülen enfeksiyonlar. Febril Nötropeni. Bilimsel tıp. (Akova M, Akan H, eds). Ankara, 2010;9-17.
4. 4. https://www.ajmc.com/journals/supplement/2017/clinical-advance-in-the-management -of-febrile-neutropenia/ guidelines-in-the-management-of-febrile- neutropenia-for- clinical-practice.
5. 5. Paesmans M, Kern WF. Tüm nötropenik hastalar aynı mı? Febril Nötropeni. Bilimsel tıp. (Akova M, Akan H, eds). Ankara, 2010;63-72.
6. 6. Hughes WT, Armstrong D, Bodey GP, et al. Guidelines for the use of antimicrobial agents in neutropenic patiens with unexplained fever. Clin Infect Dis 2002;34:730-51.
7. 7. Saba R. Febril nötropenik hastalarda klinik değerlendirme. Febril Nötropeni. Bilimsel tıp. (Akova M, Akan H, eds). Ankara, 2010;97:101.
8. 8. Napenas JJ, Brennan MT, Bahrani-Mougeot FK. Relationship between mucositis and changes in oral microflora during cancer chemotherapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:48-59.

9. 9. Wong HM. Oral complications and management strategies for patients undergoing cancer therapy. Sci World J 2014;581795.
10. 10. Van der Velden WJ, Herbers AH, Netea MG. Mucosal barrier injury, fever and infection in neutropenic patients with cancer: introducing the paradigm febrile mucositis. Br J Haematol 2014;167:441-52.
11. 11. Rossini F, Terruzzi E, Verga L, et al. A randomized clinical trial of ceftriaxone and amikacin versus piperacillin tazobactam and amikacin in febrile patients with hematological neoplasi and severe neutropenia. Support Care Cancer 2005;13:387-92.
12. 12. Cherif H, Bjorkholm M, Engervall P, et al. A prospective, randomized study comparing cefepime and imipenem-cilastatin in the empirical treatment of febrile neutropenia in patients treated for haematological malignancies. Scand J Infect Dis 2004;36:593-600.
13. 13. Viscoli C, Cometta A, Kern WV, et al. International Antimicrobial Therapy Group of the European Organization for Research and Treatment of Cancer. Piperacillin-tazobactam monotherapy in high risk febrile and neutropenic cancer patients. Clin Microbiol Infect 2006;12:212-6.
14. 14. Antoniadou A, Giamerallou H. Fever of unknown origin in febrile leukopenia. Infect Dis Clin N Am 2007;21:1055-90.
15. 15. De Pauw BE, Deresinski SC, Feld R, et al. Ceftazidime compared with piperacillin and tobramycin for the empric treatment of fever in neutropenic patients with cancer. A multicenter randomized trial. Ann Intern Med 1994;120:834-44.
16. 16. Cometta A, Zinner S, de Bock R, et al. The International Antimicrobial Therapy Cooperative Group of the European Organization for Research and Treatment of Cancer. Piperacillin-tazobactam plus amikacin versus ceftazidime plus amikacin as empric therapy for fever in granulocytopnic patients with cancer. Antimicrob Agents Chemother 1995;39:445-52.
17. 17. EORTC International Antimicrobial Tharapy Cooperative Group. Eficacy and toxicity of single daily doses of amikacin and ceftriaxone versus multiple daily doses of amikacin and ceftazidime for infections in patients with cancer and granulocytopenia. Ann Intern Med 1993;119:584-93.
18. 18. Cornely OA, Wicke T, Seifert H, et al. Once-daily oral levofloxacin monotherapy versus piperacillin/tazobactam three times a day: a randomized controlled multicenter trial in patients with in febrile neutropenia. Int J Hematol 2004;79:74-8.
19. 19. Bow EJ, Rotstein C, Noskin GA, et al. A randomized, open-label, multicenter comparative study of the efficacy and safety of piperacillin-tazobactam and cefepime emprical treatment of febrile neutropenic episodes in patients with hematologic malignancies. Clin Infect Dis 2006;43:447-59.
20. 20. Aydın K, Yılmaz M, Sönmez M, et al. Karadeniz Teknik Üniversitesi Hematoloji Kliniğinde İzlenen Febril Nötropeni Ataklarının Değerlendirilmesi. Flora 2007;12:80-5.
21. 21. Jeddi R, Achour M, Amor RB, et al. Factors associated with severe sepsis: prospective study of 94 neutropenic febrile episodes. Hematology 2010;15:28-32.
22. 22. Gençer S, Özer S, Salepçi T ve ark. Febril nötropenik olgularımızın enfeksiyonlar ve mortalite yönünden değerlendirilmesi. 6. Febril nötropeni sempozyumu, 24-27 Şubat 2005, Program ve Özet Kitabı s.151.
23. 23. Toussaint E, Bahel-Ball E, Vekemans M, et al. Causes of fever in cancer patients (prospective study over 477 episodes). Support Care Cancer 2006;14:763-9.
24. 24. Norgaard M, Larsson H, Pedersen G, et al. Risk of bacteremia and mortality in patients with haematological malignancies. Clin Microbiol Infect 2006;12:217-23.
25. 25. Rolston KVI. Challenge in the treatment of infections caused by gram-pozitive and gram- negative bacteria in patients with cancer and neutropenia. Clin Infect Dis 2005;40:246-52.
26. 26. Link H, Bohme A, Cornely OA, et al; Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO); Group Interventional Therapy of Unexplained Fever, Arbeitsgemeinschaft Supportivmassnahmen in der Onkologie (ASO) of the Deutsche Krebsgesellschaft (DKG-German Cancer Society). Antimicrobial therapy of unexplained fever in neutropenic patients--guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO), Study Group Interventional Therapy of Unexplained Fever, Arbeitsgemeinschaft Supportivmassnahmen in der Onkologie (ASO) of the Deutsche Krebsgesellschaft (DKG-German Cancer Society). Ann Hematol 2003;82:105-17.
27. 27. Akova M, Hayran M, Unal S, et al. Characteristics of infectious agents in adult cancer patients with neutropenia and fever. 13th Meeting of the International Society of Haematology. Abstract no. 633. 3-8 September 1995, İstanbul.
28. 28. Bodey G, Bueltmann B, Duguid W, et al. M.D. Anderson Cancer Center. Fungal infections in cancer patients: An international autopsy survey. Eur J Clin Microbiol Infect Dis 1992;11:99-109.
29. 29. Fridkin SK. The changing face of fungal infections in health care settings. Clin Infect Dis 2005;41:1455-60.
30. 30. De Pauw BE, Donnelly JP. Infections in the unocompromised host: general principles. In: Mandell GL, Bennett Je, Dolin R, eds. Principles and practice of infectious diseases. 5th ed. Philadelphia: Churcill Livingstone 2000:3079-90.
31. 31. Vazquez JA, Sobel JD. Mucosal candidiasis. Infect Dis Clin North Am 2002;16:793-820.
32. 32. Sain Güven G, Çakır B, Zarakolu P, et al. Febril nötropenik kanser hastalarında tedavi başarısını etkileyen faktörlerin incelenmesi. Flora 2004;9:246-51.
33. 33. Kandemir Ö, Şahin E, Tiftik N, et al. Febril nötropenik kanser hastalarında gözlenen enfeksiyonlar ve tedavi başarısını etkileyen faktörlerin değerlendirilmesi. ANKEM Derg 2006;20:98-102.
34. 34. Segal B.H, Walsh T.J, Holland S.M. Infections in cancer patient. In: DeVita, V.T Jr, Hellman S, Rosenberg S.A, eds. Cancer principles and practice of oncology. 6th ed. Philadelphia: Lippincott Williams and Wilkins 2001:2815-68.
35. 35. Wahlin YB, Granström S, Persson S, et al. Multivariate study of enterobacteria and Pseudomonas in saliva of patients with acute leukemia. Oral Surg Oral Med Oral Pathol 1991;72:300-8.
36. 36. Perez F, Adachi J, Bonomo RA. Antibiotic-resistant gram-negative bacterial infections in patients with cancer. Clin Infect Dis 2014:335-9.