Jeddi Ramzi, Achour Mériem, Amor Ramzi Ben, Aissaoui Lamia, Bouterâa Walid, Kacem Karima, Lakhal Raihane Ben, Abid Héla Ben, BelHadjAli Zaher, Turki Amel, Meddeb Balkis
Department of Hematology, Aziza Othmana University Hospital, Tunis, Tunisia.
Hematology. 2010 Feb;15(1):28-32. doi: 10.1179/102453310X12583347009577.
Severe sepsis defined as infection-induced organ dysfunction or hypoperfusion abnormalities predispose to septic shock and increased mortality in neutropenic setting. We aimed at determining predictors of severe sepsis in neutropenic patients. Between 1 October and 31 December 2007, 41 patients (21 with acute myeloid leukemia, 19 with acute lymphoid leukemia and one with autologous stem cell transplantation for a mantle cell lymphoma) with chemotherapy-induced neutropenia (<0.5 x 10(9)/l) lasting for more than 7 days were included in this study. The median age was 28 years (range: 3-58 years). All patients were on oral antibacterial (colistin and gentamicin) and anti-fungal (amphotericin B) prophylaxis. The first neutropenic febrile episode was treated with piperacillin/tazobactam and colistin IV; if the patient remains febrile at 48 h from the start of this first line of treatment, amphotericin B i.v. is added. Imipenem was introduced in the case of non-response and finally glycopeptides were introduced according to the IDSA criteria. Severe sepsis and septic shock are defined according to the criteria of the consensus conference of the ACCP/SCCM excluding the leukocyte count since all the patients were neutropenic. Ninety-four febrile episodes were observed: 27 microbiologically documented (28.7%), six clinically documented (6.3%) and 61 fever of unknown origin (65%). Microbiologically documented infections were: 13 Gram-negative organisms, 11 Gram-positive organisms and three combined (Gram+ and -). Clinically documented infections were pneumonia (two), neutropenic enterocolitis (one), sinuses infection (one) and cutaneous infection (two). Severe sepsis accounted for 22 febrile episodes. Factors associated with the occurrence of severe sepsis were: hypophosphatemia (<0.8 mmol/l; p=0.05, OR=3.9, 95% CI: 1.3-45.7), hypoproteinemia (<62 g/l; p=0.006, OR=4.1, 95% CI: 1.4-11.4) and non-adapted antibiotherapy at the onset of severe sepsis (p=0.019, OR=2.7, 95% CI: 1.02-7.39). However, heart rate/systolic blood pressure ratio <1.1 (p<0.001, OR=0.1, 95% CI: 0.03-0.31) and Creactive protein <80 mg (p=0.001, OR=0.14, 95% CI: 0.04-0.54) were not predictive.
严重脓毒症定义为感染引起的器官功能障碍或灌注异常，在中性粒细胞减少的情况下易引发感染性休克并增加死亡率。我们旨在确定中性粒细胞减少患者发生严重脓毒症的预测因素。2007年10月1日至12月31日期间，本研究纳入了41例化疗引起的中性粒细胞减少（<0.5×10⁹/L）持续超过7天的患者（21例急性髓系白血病、19例急性淋巴细胞白血病和1例因套细胞淋巴瘤接受自体干细胞移植）。中位年龄为28岁（范围：3 - 58岁）。所有患者均接受口服抗菌药物（黏菌素和庆大霉素）和抗真菌药物（两性霉素B）预防。首次中性粒细胞减少发热发作采用哌拉西林/他唑巴坦和静脉注射黏菌素治疗；如果患者从一线治疗开始48小时后仍发热，则加用静脉注射两性霉素B。若无反应则使用亚胺培南，最后根据美国感染病学会（IDSA）标准使用糖肽类药物。严重脓毒症和感染性休克根据美国胸科医师学会（ACCP）/危重病医学会（SCCM）共识会议的标准定义，但不包括白细胞计数，因为所有患者均为中性粒细胞减少。共观察到94次发热发作：27次有微生物学记录（28.7%），6次有临床记录（6.3%），61次为不明原因发热（65%）。微生物学记录的感染包括：13种革兰阴性菌、11种革兰阳性菌和3种混合菌（革兰阳性菌和革兰阴性菌）。临床记录的感染包括肺炎（2例）、中性粒细胞减少性小肠结肠炎（1例）、鼻窦感染（1例）和皮肤感染（2例）。严重脓毒症占22次发热发作。与严重脓毒症发生相关的因素有：低磷血症（<0.8 mmol/L；p = 0.05，OR = 3.9，95%可信区间：1.3 - 45.7）、低蛋白血症（<62 g/L；p = 0.006，OR = 4.1，95%可信区间：1.4 - 11.4）以及严重脓毒症发作时抗菌治疗不恰当（p = 0.019，OR = 2.7，95%可信区间：1.02 - 7.39）。然而，心率/收缩压比值<1.1（p < 0.001，OR = 0.1，95%可信区间：0.03 - 0.31）和C反应蛋白<80 mg（p = 0.001，OR = 0.14，95%可信区间：0.04 - 0.54）无预测价值。
