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Notfall + Rettungsmedizin

, Volume 20, Issue 3, pp 206–215 | Cite as

Infektionen bei Patienten mit hämatologisch-onkologischen Erkrankungen

Leitthema
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Zusammenfassung

Hintergrund

Infektionen stellen eine häufige und schwerwiegende Komplikation bei Patienten mit hämatologisch-onkologischen Erkrankungen dar, wobei das individuelle Infektionsrisiko von verschiedenen Faktoren, wie z. B. Art der antineoplastischen Therapie bestimmt wird.

Fragestellungen

Zentrale Fragen sind die Bestimmung der Inzidenz von Infektionen bei hämatologisch-onkologischen Patienten sowie Beschreibungen von verursachenden Erregern und Risikofaktoren und Darstellungen von Empfehlungen zur Diagnostik und antimikrobiellen Therapie bei diesen Patienten.

Material und Methoden

Es wurde eine selektive Literaturrecherche durchgeführt und die Expertenempfehlungen diskutiert.

Ergebnisse

Infektionen können bei Tumorpatienten alle Organsysteme betreffen und durch Bakterien, Pilze, Viren und Parasiten verursacht sein. Neben der febrilen Neutropenie werden andere bakterielle und virale Infektionen (z. B. Herpes Zoster) häufig bei diesen Patienten beobachtet. Patienten mit Hochrisikoneutropenie (absolute Neutrophilenzahl <100/µl für >7 Tage) oder Empfänger einer allogenen hämatopoetischen Stammzelltransplantation weisen zudem ein erhöhtes Risiko für mykotische (z. B. pulmonale Aspergillose) sowie parasitäre Infektionen (z. B. ZNS-Toxoplasmose) auf.

Die Diagnostik umfasst Basismaßnahmen (z. B. Entnahme von Blutkulturen) und weitere Untersuchungen, die symptomorientiert durchgeführt werden (z. B. Thorax-CT). In therapeutischer Hinsicht wird ein empirischer von einem präemptiven bzw. einem zielgerichtetem Therapieansatz abgegrenzt.

Schlussfolgerungen

Infektionen tragen wesentlich zur Morbidität und Mortalität von Patienten mit hämatologisch-onkologischen Erkrankungen bei. Die zeitgerechte Einleitung adäquater diagnostischer und therapeutischer Maßnahmen ist entscheidend, um die Mortalität bei diesen Patienten zu reduzieren.

Schlüsselwörter

Infektionen Febrile Neutropenie Allogene hämatopoetische Stammzelltransplantation Pulmonale Aspergillose Antimikrobielle Therapie 

Infections in patients with hematological–oncological disorders

Abstract

Background

Infections represent a frequent and severe complication of patients with hematological-oncological disorders. The individual infection risk is determined by the presence of various risk factors such as the type of antineoplastic treatment.

Objectives

The purpose of this work was to determine the incidence of infections in patients with hematological-oncological disorders. The spectrum of causative agents and risk factors in these patients are also described and recommendations on diagnostic workup and antimicrobial treatment are given.

Materials and methods

Selective literature search, discussion of expert opinions.

Results

Infections in cancer patients may involve different organ systems and might be caused by bacteria, fungi, viruses, and parasites. Common infection types include febrile neutropenia in addition to other bacterial and viral infections (e. g., herpes zoster). Patients with high-risk neutropenia (absolute neutrophile count <100/µl for >7 days) and recipients of an allogeneic hematopoietic stem cell transplantation also show an increased risk for fungal (e. g., pulmonary aspergillosis) and parasitic infections (e. g., CNS toxoplasmosis). Diagnosis is based on routine procedures (such as blood cultures) and clinically-driven investigations (e. g., CT scan of the lungs). Antimicrobial treatment might be empiric, preemptive, or targeted.

Conclusions

Infections significantly contribute to morbidity and mortality of patients with hematological-oncological disorders. The timely initiation of adequate diagnostics and antimicrobial treatment is crucial to reduce the mortality in these patients.

Keywords

Infections Febrile neutropenia Allogeneic hematopoietic stem cell transplantation Pulmonary aspergillosis Antimicrobial treatment 

Notes

Danksagung

Die Autoren danken Herrn Prof. Dr. med. Jens Ricke, Klinik für Radiologie und Nuklearmedizin, Universitätsklinikum Magdeburg, für die zur Verfügung gestellten CT-Abbildungen.

Einhaltung ethischer Richtlinien

Interessenkonflikt

M. Christopeit erhielt Forschungsunterstützung: DFG, DGHO/José Carreras Leukämie-Stiftung, Hamburger Krebsgesellschaft e. V., Erich und Gertrud Roggenbuck-Stiftung, MSD Sharp & Dohme (Stipendium Onkologie 2013); Tätigkeiten in Beratungsgremien: Basilea Pharmaceutika, MSD Sharp & Dohme; Zuwendungen für Vorträge: Basilea Pharmaceutika, MSD Sharp & Dohme; Reiseunterstützung für Kongresse: Neovii Biotech, Takeda Pharma, Gilead Sciences, MSD Sharp & Dohme, Celgene. M. Schmidt-Hieber, und E. Schalk geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Bennett CL, Djulbegovic B, Norris LB et al (2013) Colony-stimulating factors for febrile neutropenia during cancer therapy. N Engl J Med 368(12):1131–1139CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Bleggi-Torres LF, de Medeiros BC, Werner B et al (2000) Neuropathological findings after bone marrow transplantation: an autopsy study of 180 cases. Bone Marrow Transplant 25(3):301–307CrossRefPubMedGoogle Scholar
  3. 3.
    Buchheidt D, Böhme A, Cornely OA et al (2003) Diagnosis and treatment of documented infections in neutropenic patients-recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Hematol 82(Suppl 2):S127–S132CrossRefPubMedGoogle Scholar
  4. 4.
    Chao C, Page JH, Yang S et al (2014) History of chronic comorbidity and risk of chemotherapy-induced febrile neutropenia in cancer patients not receiving G‑CSF prophylaxis. Ann Oncol 25(9):1821–1829CrossRefPubMedGoogle Scholar
  5. 5.
    Cometta A, Kern WV, de Bock R et al (2003) Vancomycin versus placebo for treating persistent fever in patients with neutropenic cancer receiving piperacillin-tazobactam monotherapy. Clin Infect Dis 37(3):382–389CrossRefPubMedGoogle Scholar
  6. 6.
    Corti M, Palmero D, Eiguchi K (2009) Respiratory infections in immunocompromised patients. Curr Opin Pulm Med 15(3):209–217CrossRefPubMedGoogle Scholar
  7. 7.
    Crawford J, Dale DC, Lyman GH (2004) Chemotherapy-induced neutropenia: risks, consequences, and new directions for its management. Cancer 100(2):228–237CrossRefPubMedGoogle Scholar
  8. 8.
    Cullen MH, Billingham LJ, Gaunt CH et al (2007) Rational selection of patients for antibacterial prophylaxis after chemotherapy. J Clin Oncol 25(30):4821–4828CrossRefPubMedGoogle Scholar
  9. 9.
    Feld R (2008) Bloodstream infections in cancer patients with febrile neutropenia. Int J Antimicrob Agents 32(Suppl 1):S30–S33CrossRefPubMedGoogle Scholar
  10. 10.
    Flowers CR, Seidenfeld J, Bow EJ et al (2013) Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 31(6):794–810CrossRefPubMedGoogle Scholar
  11. 11.
    Freifeld AG, Bow EJ, Sepkowitz KA et al (2011) 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 52(4):e56–e93CrossRefPubMedGoogle Scholar
  12. 12.
    García de Guadiana-Romualdo L, Español-Morales I, Cerezuela-Fuentes P et al (2015) Value of lipopolysaccharide binding protein as diagnostic marker of infection in adult cancer patients with febrile neutropenia: comparison with C‑reactive protein, procalcitonin, and interleukin 6. Support Care Cancer 23(7):2175–2182CrossRefPubMedGoogle Scholar
  13. 13.
    Hagel S, Pletz MW, Brunkhorst FM et al (2013) Bakteriämie und Sepsis (Bacteremia and sepsis). Internist (Berl) 54(4):399–407CrossRefGoogle Scholar
  14. 14.
    Kuderer NM, Dale DC, Crawford J et al (2006) Mortality, morbidity, and cost associated with febrile neutropenia in adult cancer patients. Cancer 106(10):2258–2266CrossRefPubMedGoogle Scholar
  15. 15.
    Kumar A, Roberts D, Wood KE et al (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 34(6):1589–1596CrossRefPubMedGoogle Scholar
  16. 16.
    Link H, Maschmeyer G, Meyer P et al (1994) Interventional antimicrobial therapy in febrile neutropenic patients. Study Group of the Paul Ehrlich Society for Chemotherapy. Ann Hematol 69(5):231–243CrossRefPubMedGoogle Scholar
  17. 17.
    Maschmeyer G, Carratalà J, Buchheidt D et al (2015) Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients (allogeneic SCT excluded): updated guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Oncol 26(1):21–33CrossRefPubMedGoogle Scholar
  18. 18.
    Mokart D, Saillard C, Sannini A et al (2014) Neutropenic cancer patients with severe sepsis: need for antibiotics in the first hour. Intensive Care Med 40(8):1173–1174CrossRefPubMedGoogle Scholar
  19. 19.
    de Naurois J, Novitzky-Basso I, Gill MJ et al (2010) Management of febrile neutropenia: ESMO Clinical Practice Guidelines. Ann Oncol 21(Suppl 5):v252–v256CrossRefPubMedGoogle Scholar
  20. 20.
    Penack O, Becker C, Buchheidt D et al (2014) Management of sepsis in neutropenic patients: 2014 updated guidelines from the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO). Ann Hematol 93(7):1083–1095CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Retamar P, Portillo MM, López-Prieto MD et al (2012) Impact of inadequate empirical therapy on the mortality of patients with bloodstream infections: a propensity score-based analysis. Antimicrob Agents Chemother 56(1):472–478CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Ritchie S, Palmer S, Ellis-Pegler R (2007) High-risk febrile neutropenia in Auckland 2003-2004: the influence of the microbiology laboratory on patient treatment and the use of pathogen-specific therapy. Intern Med J 37(1):26–31CrossRefPubMedGoogle Scholar
  23. 23.
    Rolston KV (2015) Infections in patients with acute leukemia. In: Maschmeyer G, Rolston KV (Hrsg) Infections in Hematology, 1. Aufl. Springer, Berlin, S 3–23Google Scholar
  24. 24.
    Schalk E, Bohr URM, König B et al (2010) Clostridium difficile-associated diarrhoea, a frequent complication in patients with acute myeloid leukaemia. Ann Hematol 89(1):9–14CrossRefPubMedGoogle Scholar
  25. 25.
    Schalk E, Geginat G, Schulz C et al (2014) The incidence of norovirus infections in cancer patients shows less seasonal variability compared to patients with other diseases. Ann Hematol 93(5):889–890CrossRefPubMedGoogle Scholar
  26. 26.
    Schalk E, Tammer I, Heidel FH (2014) Germ and hematology: underlying disease influences diversity of germ spectra and antibiotic therapy. Infect Control Hosp Epidemiol 35(2):208–210CrossRefPubMedGoogle Scholar
  27. 27.
    Schellongowski P (2013) Der hämatologisch-onkologische Patient auf der Intensivstation. Therapieziele-Ethik-Palliation (Cancer patients in the intensive care unit. Goals of therapy, ethics, and palliation). Med Klin Intensivmed Notfmed 108(3):203–208CrossRefPubMedGoogle Scholar
  28. 28.
    Schiel X, Link H, Maschmeyer G et al (2006) A prospective, randomized multicenter trial of the empirical addition of antifungal therapy for febrile neutropenic cancer patients: results of the Paul Ehrlich Society for Chemotherapy (PEG) Multicenter Trial II. Infection 34(3):118–126CrossRefPubMedGoogle Scholar
  29. 29.
    Schmidt-Hieber M, Silling G, Schalk E et al (2016) CNS infections in patients with hematological disorders (including allogeneic stem cell transplantation)-Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Oncol 27(7):1207–1225CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Serody JS, Berrey MM, Albritton K et al (2000) Utility of obtaining blood cultures in febrile neutropenic patients undergoing bone marrow transplantation. Bone Marrow Transplant 26(5):533–538CrossRefPubMedGoogle Scholar
  31. 31.
    Singer M, Deutschman CS, Seymour CW et al (2016) The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 315(8):801–810CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Smith TJ, Bohlke K, Lyman GH et al (2015) Recommendations for the use of WBC growth factors: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 33(28):3199–3212CrossRefPubMedGoogle Scholar
  33. 33.
    Staudinger T, Schellongowski P (2013) Der chronisch kritisch kranke Patient aus der Perspektive des Hämatoonkologen (Chronic critically ill patients from the perspective of hematologists/oncologists). Med Klin Intensivmed Notfmed 108(4):295–302CrossRefPubMedGoogle Scholar
  34. 34.
    Staudinger T, Stoiser B, Müllner M et al (2000) Outcome and prognostic factors in critically ill cancer patients admitted to the intensive care unit. Crit Care Med 28(5):1322–1328CrossRefPubMedGoogle Scholar
  35. 35.
    Styczynski J, Reusser P, Einsele H et al (2009) Management of HSV, VZV and EBV infections in patients with hematological malignancies and after SCT: guidelines from the Second European Conference on Infections in Leukemia. Bone Marrow Transplant 43(10):757–770CrossRefPubMedGoogle Scholar
  36. 36.
    Tomblyn M, Chiller T, Einsele H et al (2009) Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant 15(10):1143–1238CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Vehreschild JJ, Morgen G, Cornely OA et al (2013) Evaluation of an infectious disease consultation programme in a German tertiary care hospital. Infection 41(6):1121–1128CrossRefPubMedGoogle Scholar
  38. 38.
    Vehreschild MJGT, Meissner AMK, Cornely OA et al (2011) Clinically defined chemotherapy-associated bowel syndrome predicts severe complications and death in cancer patients. Haematologica 96(12):1855–1860CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Vehreschild MJGT, Vehreschild JJ, Hübel K et al (2013) Diagnosis and management of gastrointestinal complications in adult cancer patients: evidence-based guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Oncol 24(5):1189–1202CrossRefPubMedGoogle Scholar
  40. 40.
    Weber C, Maas R, Steiner P et al (1999) Wertigkeit der digitalen Thoraxaufnahme bei der Detektion von Lungeninfiltraten knochenmarktransplantierter Patienten in der Aplasie (Importance of digital thoracic radiography in the diagnosis of pulmonary infiltrates in patients with bone marrow transplantation during aplasia). Rofo 171(4):294–301CrossRefPubMedGoogle Scholar

Copyright information

© Springer Medizin Verlag Berlin 2016

Authors and Affiliations

  1. 1.Klinik für Hämatologie, Onkologie und TumorimmunologieHELIOS Klinik Berlin-BuchBerlinDeutschland
  2. 2.Klinik für StammzelltransplantationUniversitätsklinikum Hamburg-EppendorfHamburgDeutschland
  3. 3.Klinik für Hämatologie und OnkologieOtto-von-Guericke Universität MagdeburgMagdeburgDeutschland

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