Smith S R, Cheesbrough J, Harding I, Davies J M
University Department of Haematology, Royal Liverpool Hospital.
Br J Haematol. 1990 Dec;76 Suppl 2:54-6. doi: 10.1111/j.1365-2141.1990.tb07938.x.
The exact timing of the introduction of the glycopeptide antibiotics teicoplanin and vancomycin in the management of the febrile neutropenic patient continues to be controversial. However, there are certain firm criteria now emerging. Bacteraemia can be eradicated with a success rate approaching 100% in cases where the organism can be identified and shown to be sensitive. Approximately 65% of cases of soft-tissue infection, usually occurring with the use of a Hickman or equivalent indwelling catheter, are associated with the presence on culture of Gram-positive organisms of presumed skin origin. Such infection is an indication for the early use of antibiotics with proven activity against coagulase-negative staphylococci and diptheroids. Resolution of fever in up to 50% of cases may result from using 'planned progressive therapy': the introduction of specific Gram-positive cover in patients who have failed to respond at 48-72 h to regimens such as a ureidopenicillin or a third-generation cephalosporin with or without an aminoglycoside. This approach reduces the number of patients who go on to receive empirical amphotericin B intravenously for presumed fungal infection. Using teicoplanin or vancomycin as first-line agents in the empirical treatment of first fever in febrile neutropenic patients is perhaps more controversial. Recent developments which include using quinolone-based prophylaxis more widely and introducing cytokines to reduce the period of neutropenia may increase the likelihood that a neutropenic patient's febrile episode will be due to a Gram-positive organism. The dilemma of choosing broad-spectrum monotherapy or targeted combination therapy in the situation remains unresolved. Current studies, however, should help to clarify this situation. Finally, other current studies of teicoplanin and vancomycin as prophylactic agents administered either orally or systemically, may provide additional indications for their use in the neutropenic patient.
在发热性中性粒细胞减少患者的治疗中，糖肽类抗生素替考拉宁和万古霉素的确切使用时机仍存在争议。然而，目前正在出现一些明确的标准。在能够鉴定出病原体并证明其敏感的情况下，菌血症的根除成功率接近100%。大约65%的软组织感染病例，通常发生在使用希克曼或类似的留置导管时，与培养出的推测源自皮肤的革兰氏阳性菌有关。这种感染是早期使用对凝固酶阴性葡萄球菌和类白喉杆菌有 proven 活性的抗生素的指征。高达50%的病例中发热的消退可能是由于采用“计划性渐进治疗”：对于在48 - 72小时内对诸如脲基青霉素或第三代头孢菌素联合或不联合氨基糖苷类药物的治疗方案无反应的患者，引入特定的革兰氏阳性菌覆盖治疗。这种方法减少了因推测真菌感染而继续接受经验性静脉注射两性霉素B的患者数量。在发热性中性粒细胞减少患者首次发热的经验性治疗中，将替考拉宁或万古霉素作为一线药物可能更具争议性。最近的进展包括更广泛地使用基于喹诺酮的预防措施以及引入细胞因子以缩短中性粒细胞减少期，这可能增加中性粒细胞减少患者发热发作是由革兰氏阳性菌引起的可能性。在这种情况下选择广谱单一疗法还是靶向联合疗法的困境仍未解决。然而，目前的研究应该有助于澄清这种情况。最后，目前关于替考拉宁和万古霉素作为口服或全身给药的预防药物的其他研究，可能为它们在中性粒细胞减少患者中的使用提供更多指征。
