Guy Leverger

Epidemiology and Risk Factors for Gram- Positive Coccal Infections in Neutropenia: Toward a More Targeted Antibiotic Strategy

The objective of this study was to evaluate the risk of acquiring gram-positive coccal infections in febrile neutropenic patients and to develop risk indexes for gram-positive and streptococcal infections. This prospective, multicenter study included 513 patients. The prevalence of gram-positive coccal infections was 21% (14% were staphylococcal infections and 7.8% were streptococcal infections). The mortality rate during the month after study enrollment was 5%. On multivariate analysis, the occurrence of gram-positive coccal infections was significantly associated with receipt of high-dose cytarabine therapy, proton pump inhibitors, and gut decontamination with colimycin without glycopeptides and presence of chills. Staphylococcal infection was significantly associated with use of nonabsorbable colimycin, and streptococcal infection was associated with diarrhea, use of nonabsorbable antifungals, receipt of high-dose cytarabine, and gut decontamination with colimycin. The relative risks for streptococcal infection were 2.9, 13.2, and 20.7 in the presence of 1, 2, and > or =3 parameters, respectively. Risk factors for staphylococcal and streptococcal infections differ among neutropenic patients. A simple scoring system for predicting streptococcal infection is proposed.

Résultats d’une enquête de pratique en onco-hématologie réalisée en France en 2001

Resume A la suite de la mise en place de prises en charge ambulatoires, Il est apparu necessaire de connaitre le mode d’organisation des equipes hospitalieres d’oncologie et d’hematologie. Des questions ont ete posees concernant l’effectif medical a l’hopital, les regles d’organisation de ces prises en charge, les modes d’organisation a domicile, les choix therapeutiques. Pourcentage de reponses Trente et un centres (46 %) ont repondu a l’enquete : 20 centres hospitaliers dont 5 services de pediatrie et 11 centres anticancereux. Deux tiers environ des centres francais confrontes a des neutropenies febriles de courte duree ont opte pour une prise en charge a domicile. Un constat Si la responsabilite de l’entourage et celle du medecin traitant sont nettement impliquees, le medecin generaliste ne dispose souvent ni de la formation, ni des informations necessaires pour gerer l’evaluation initiale ainsi qu’une evolution potentiellement defavorable. Or, il est le pivot du systeme de soins extra-hospitalier.

Antibiothérapie ambulatoire chez les enfants neutropéniques fébriles: Analyse de la littérature

NEW STRATEGIES: Fever in a neutropenic patient requires the rapid initiation of a broad spectrum antibiotic and continued until correction of the neutropenia. Several studies have been conducted recently in order to define the populations of children in whom the antibiotherapy could be suspended early without risk of relapse of fever and/or severe infection. Moreover, the high costs of hospitalisation and the limited number of beds in the departments of Paediatric Oncology Haematology have led to studies on the feasibility of an antibiotherapy at home. THE EARLY SUSPENSION OF THE ANTIBIOTHERAPY: The criteria retained in several studies for the early suspension of the antibiotherapy have been: apyrexia for at least 24 hours, a satisfactory clinical status, the absence of positive haemocultures and haematological signs showing the end of aplasia in patients in remission of their disease. Studies have confirmed the possibility of early suspension of intravenous antibiotics in low-risk patients, without fever and without microbiological signs. THE PLACE OF ORAL ANTIBIOTICS: In several comparative studies, the success rate with intravenous antibiotics and oral antibiotics was comparable. The rate of failures was greater in patients with severe initial neutropenia. OUTPATIENT ANTIBIOTICS: In children, 2 types of studies have been conducted. The first studied the feasibility of an antibiotherapy at home following antibiotherapy in the hospital in order to reduce the costs and duration of hospitalisation. The others proposed an antibiotherapy at home from the start, either with the intravenous or the oral route. Following all these studies, it appeared that, in certain low-risk neutropenic children with fever, not only the antibiotics could be suspended before the complete correction of the neutropenia, but also a large spectrum oral antibiotherapy could replace the intravenous antibiotherapy and outpatient treatment would therefore be feasible.Resume Nouvelles strategies La fievre chez un patient neutropenique impose la mise en route rapide d’une antibiotherapie a large spectre poursuivie classiquement jusqu’a la correction de la neutropenie. Plusieurs etudes ont ete menees recemment afin de definir des populations d’enfants chez qui l’antibiotherapie pouvait etre arretee precocement sans risque de reprise thermique et/ou d’infection grave. En outre, le cout eleve de l’hospitalisation et le nombre limite de lits dans les services d’hematologie oncologie pediatrique ont conduit a des etudes de faisabilite d’une antibiotherapie a domicile. Arret precoce de l’antibiotherapie Les criteres retenus dans plusieurs etudes pour un arret precoce de l’antibiotherapie ont ete une apyrexie d’au moins 24 heures, un etat clinique satisfaisant, une absence d’hemocultures positives et des signes hematologiques de sortie d’aplasie chez des patients en remission de leur maladie. Des etudes ont confirme la possibilite d’un arret precoce de l’antibiotherapie parenterale chez des patients a faible risque, apyretiques et sans documentation microbiologique. Place de l’antibiotherapie orale Dans plusieurs etudes comparatives, les taux de succes de l’antibiotherapie intraveineuse et de l’antibiotherapie orale sont comparables. Les taux d’echec sont plus importants en cas de neutropenie profonde initiale. Antibiotherapie ambulatoire Chez l’enfant, 2 sortes d’essais ont ete realises. Les premiers ont etudie la faisabilite d’une antibiotherapie a domicile apres une antibiotherapie realisee a l’hopital afin de reduire les couts et les durees d’hospitalisation. Les autres ont propose d’emblee une antibiotherapie a domicile, soit par voie intraveineuse soit par voie orale. A la suite de ces etudes, il apparait que, chez certains enfants neutropeniques febriles a faible risque, non seulement l’antibiotherapie peut etre interrompue avant la correction definitive de la neutropenie, mais une antibiotherapie orale a large spectre pourrait remplacer l’antibiotherapie intraveineuse des lors qu’une prise en charge ambulatoire est realisable.