Garnica M, Maiolino A, Nucci M
Serviço de Hematologia, Hospital Universitário, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil.
Braz J Med Biol Res. 2009 Mar;42(3):289-93. doi: 10.1590/s0100-879x2009000300010.
The epidemiology of bacteremia developing during neutropenia has changed in the past decade, with the re-emergence of Gram-negative (GN) bacteria and the development of multidrug resistance (MDR) among GN bacteria. We conducted a case-control study in order to identify factors associated with bacteremia due to multidrug-resistant Gram-negative (MDRGN) isolates in hematopoietic stem cell transplant recipients. Ten patients with MDRGN bacteremia were compared with 44 patients with GN bacteremia without MDR. Bacteremia due to Burkholderia or Stenotrophomonas sp was excluded from analysis (3 cases), because the possibility of intrinsical resistance. Infection due to MDRGN bacteria occurred in 2.9% of 342 hematopoietic stem cell transplant recipients. Klebsiella pneumoniae was the most frequent MDRGN (4 isolates), followed by Pseudomonas aeruginosa (3 isolates). Among non-MDRGN, P. aeruginosa was the most frequent agent (34%), followed by Escherichia coli (30%). The development of GN bacteremia during the empirical treatment of febrile neutropenia (breakthrough bacteremia) was associated with MDR (P < 0.001, odds ratio = 32, 95% confidence interval = 5_190) by multivariate analysis. Bacteremia due to MDRGN bacteria was associated with a higher death rate by univariate analysis (40 vs 9%; P = 0.03). We were unable to identify risk factors on admission or at the time of the first fever, but the occurrence of breakthrough bacteremia was strongly associated with MDRGN bacteria. An immediate change in the antibiotic regimen in such circumstances may improve the prognosis of these patients.
在过去十年中，中性粒细胞减少期间发生的菌血症流行病学发生了变化，革兰氏阴性（GN）菌再度出现，且GN菌中出现了多重耐药（MDR）情况。我们开展了一项病例对照研究，以确定造血干细胞移植受者中与耐多药革兰氏阴性（MDRGN）菌血症相关的因素。将10例MDRGN菌血症患者与44例无MDR的GN菌血症患者进行比较。分析中排除了由伯克霍尔德菌属或嗜麦芽窄食单胞菌引起的菌血症（3例），因为存在固有耐药的可能性。342例造血干细胞移植受者中有2.9%发生了MDRGN菌感染。肺炎克雷伯菌是最常见的MDRGN菌（4株），其次是铜绿假单胞菌（3株）。在非MDRGN菌中，铜绿假单胞菌是最常见的病原体（34%），其次是大肠埃希菌（30%）。经多因素分析，发热性中性粒细胞减少经验性治疗期间发生的GN菌血症（突破性菌血症）与MDR相关（P<0.001，比值比=32，95%置信区间=5-190）。单因素分析显示，MDRGN菌血症的死亡率更高（40%对9%；P=0.03）。我们无法确定入院时或首次发热时的危险因素，但突破性菌血症的发生与MDRGN菌密切相关。在这种情况下立即改变抗生素治疗方案可能会改善这些患者的预后。
