Frère P, Hermanne J-P, Debouge M-H, Fillet G, Beguin Y
Department of Medicine, Division of Haematology, University of Liège, Liège, Belgium.
Bone Marrow Transplant. 2002 Apr;29(7):589-94. doi: 10.1038/sj.bmt.1703413.
Adequate infection prophylaxis and empirical antibiotic therapy are of critical importance after hematopoietic stem cell transplantation (HSCT). We examined the evolution of bacterial susceptibility to antibiotics in 492 patients (198 allografts and 294 autografts) transplanted between 1982 and 1999 and evaluated whether ciprofloxacin prophylaxis and an empirical antibiotic regimen (glycopeptide + third-generation cephalosporin) were still valid. We collected all susceptibility tests performed during the initial hospitalization on blood cultures as well as routine surveillance cultures and analyzed susceptibility to ciprofloxacin and to major antibiotics used in our unit. Gram-positive cocci rapidly became resistant to ciprofloxacin (susceptibility around 70% in 1990 to less than 20% in 1998) but sensitivity to glycopeptides remained unaltered. There was a rapid decline in the number of patients colonized with Gram-negative bacilli in the early years of ciprofloxacin prophylaxis. However, susceptibility to ciprofloxacin fell sharply from around 90% in 1990 to around 30% in 1999. In parallel, susceptibility to ceftazidime also decreased to less than 80% in recent years. Piperacillin (+/- tazobactam) did not show any variation over time and its efficacy remained too low (about 60%). Imipenem as well as recently introduced cefepim and meropenem showed stable and excellent profiles (>90% susceptibility).
(1) quinolone prophylaxis has now lost most of its value; (2) the choice of a third-generation cephalosporin for empirical antibiotic therapy may no longer be the best because of the emergence of Gram-negative strains resistant to beta-lactamases, such as Enterobacter sp. More appropriate regimens of empirical antibiotic therapy in HSCT recipients may be based on the use of a carbapenem or fourth-generation cephalosporin.
造血干细胞移植（HSCT）后，充分的感染预防和经验性抗生素治疗至关重要。我们研究了1982年至1999年间接受移植的492例患者（198例同种异体移植和294例自体移植）中细菌对抗生素敏感性的演变情况，并评估环丙沙星预防用药和经验性抗生素方案（糖肽类 + 第三代头孢菌素）是否仍然有效。我们收集了初次住院期间对血培养以及常规监测培养物进行的所有药敏试验，并分析了对环丙沙星和本单位使用的主要抗生素的敏感性。革兰氏阳性球菌对环丙沙星的耐药性迅速上升（1990年敏感性约为70%，到1998年降至20%以下），但对糖肽类的敏感性保持不变。在环丙沙星预防用药的早期，革兰氏阴性杆菌定植患者的数量迅速下降。然而，对环丙沙星的敏感性从1990年的约90%急剧降至1999年的约30%。与此同时，近年来对头孢他啶的敏感性也降至80%以下。哌拉西林（± 他唑巴坦）随时间未显示任何变化，其疗效仍然很低（约60%）。亚胺培南以及最近引入的头孢吡肟和美罗培南显示出稳定且优异的药敏谱（敏感性>90%）。
（1）喹诺酮类预防用药现在已失去大部分价值；（2）由于出现了对β-内酰胺酶耐药的革兰氏阴性菌株，如肠杆菌属，选择第三代头孢菌素进行经验性抗生素治疗可能不再是最佳选择。HSCT受者更合适的经验性抗生素治疗方案可能基于碳青霉烯类或第四代头孢菌素的使用。
