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Febrile Neutropenie: Praktische Aspekte

Febrile neutropenia: Practical aspects

  • Übersicht
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Zusammenfassung

□ Hintergrund

Infektionen stellen eine bedeutende Mortalitätsursache bei neutropenischen Patienten dar. Sie führen zu langen Hospitalisierungsphasen und kostenintensiven therapeutischen Maßnahmen. In der vorliegenden Übersicht werden aktuelle Strategien zur Prophylaxe und Therapie der febrilen Neutropenie unter praktischen und pharmakoökonomischen Aspekten diskutiert.

□ Prophylaxe und Therapie

Prophylaktisch eingesetzte hygienische und medikamentöse Maßnahmen reduzieren die Infektionsrate. Bei Neutropenie und Fieber unklarer Genese werden initial Kombinationen aus einem Aminoglykosid und einem Ureidopenicillin oder Cephalosporin der dritten Generation eingesetzt. Kombinationen zweier β-Lactam-Antibiotika sind bei gleicher Effektivität weniger toxisch, dafür aber meist kostenintensiver. Monotherapien mit Carbapenemen, Ceftazidim oder Cefepim bieten vergleichbare Ansprechraten. Versagt das Erstregime, wird nach drei bis vier Tagen die Kombination aus einem Carbapenem, einem Glykopeptidantibiotikum und Amphotericin B eingesetzt. Bei Nachweis von Lungeninfiltraten sollte Amphotericin B bereits initial hinzugefügt werden. Durch Vergleich von Tagestherapiekosten, Applikationsfrequenz und Toxizität der jeweiligen Antibiotika könnten die Gesamtaufwendungen verringert werden. Der prophylaktische oder interventionelle Einsatz von Wachstumsfaktoren wird nur bei speziellen Risikokonstellationen empfohlen.

□ Schlußfolgerung und Ausblick

Das beschriebene Vorgehen führt bei der febrilen Neutropenie zu einer Ansprechrate von über 90%. Wichtig ist die kalkulierte Eskalation der empirischen Antibiotikatherapie zu definierten Zeitpunkten. Ob bei ausgewählten Patienten eine ambulante Therapie möglich ist, sollte noch weiter untersucht werden.

Abstract

□ Background

Infections are a major cause of mortality in neutropenic patients. They require long hospital stays and highly expensive therapeutic measures. In this review we discuss the practical and pharmaco-economic aspects of the management of febrile neutropenia.

□ Prevention and Therapy

Prevention of fever of unknown origin (FUO) demands hygienic and antimicrobiotic measures. First-line antibiotic therapy consists of an aminoglycoside combined with an ureidopenicillin or a 3rd-generation cephalosporin. Double ß-lactam antibiotic combinations are equally effective and less toxic, but more expensive. Monotherapy with carbapenems, ceftazidime, or cefepime appear to offer comparable efficacy. Lung infiltrates require immediate treatment with amphotericin B. If the initial therapeutic regime fails, a carbapenem plus a glycopeptide antibiotic and a parenteral antimycotic drug should be applied after 3 to 4 days. The prophylactic or interventional administration of hematopoietic growth factors is only indicated in special high-risk situations.

□ Conclusions

Using the described therapeutic procedure, the response rate exceeds 90%. Consistent, step-wise escalating administration of antibiotics is essential. More evaluation is needed to determine whether selected patients with febrile neutropenia can be treated on an outpatient basis.

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  1. II. Medizinische Klinik und Poliklinik, Christian-Albrechts-Universität Kiel, Chemnitzstraße 33, D-24116, Kiel

    Pontus Harten, Bärbel Seyfarth & Norbert Schmitz

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  1. Pontus Harten
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Harten, P., Seyfarth, B. & Schmitz, N. Febrile Neutropenie: Praktische Aspekte. Med Klin 93, 598–611 (1998). https://doi.org/10.1007/BF03042675

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