Klastersky J
Service de Médecine Interne, Institut Jules Bordet, Université Libre de Bruxelles, Belgium.
Ann Oncol. 1990 Jul;1(4):255-61. doi: 10.1093/oxfordjournals.annonc.a057743.
Results from clinical trials conducted over the past 15 years suggest the following: a) Early empiric therapy with broad-spectrum antibiotics directed against Gram-negative bacillary bacteremia is necessary in febrile granulocytopenic cancer patients; b) The level and dynamics of the granulocyte count are extremely important in determining the outcome of bacteremia; c) Most empiric antimicrobial regimens will require therapeutic modifications; these alterations are necessary and contribute to a high overall success rate; d) Only microbiologically documented infections and especially bacteremias are useful for comparison of initial response to antimicrobial regimens; e) The response rate of Gram-negative bacillary bacteremia is clearly influenced by the susceptibility of the causative pathogen to the beta-lactam component of the empiric regimen; emergence of resistance to some beta-lactam antibiotics is quite common and necessitates successive modifications of empiric regimens with time; f) The combination of an anti-pseudomonal beta-lactam with an aminoglycoside is recommended as the standard for empiric therapy in febrile granulocytopenic cancer patients, especially in those with severe and persistent granulocytopenia who are suspected of having Gram-negative bacillary bacteremia; less neutropenic and/or asymptomatic patients may do well with monotherapy; g) Gram-positive pathogens have become a common cause of bacteremia in granulocytopenic cancer patients; the response rate to empiric regimens may be suboptimal but the associated mortality is low; h) Patients with severe granulocytopenia and protracted fever whose blood cultures remain negative are at high risk for contracting fungal infections; in these patients, empiric antifungal agents are probably indicated.
过去15年进行的临床试验结果表明如下：a）对于发热性粒细胞减少的癌症患者，使用针对革兰氏阴性杆菌菌血症的广谱抗生素进行早期经验性治疗是必要的；b）粒细胞计数的水平和动态变化在决定菌血症的转归方面极为重要；c）大多数经验性抗菌方案都需要进行治疗调整；这些调整是必要的，并且有助于获得较高的总体成功率；d）只有微生物学证实的感染，尤其是菌血症，才有助于比较对抗菌方案的初始反应；e）革兰氏阴性杆菌菌血症的反应率显然受到致病病原体对经验性方案中β-内酰胺成分敏感性的影响；对某些β-内酰胺抗生素产生耐药性的情况相当常见，因此需要随着时间的推移对经验性方案进行连续调整；f）推荐将抗假单胞菌β-内酰胺与氨基糖苷类药物联合使用，作为发热性粒细胞减少癌症患者经验性治疗的标准，尤其是那些怀疑患有革兰氏阴性杆菌菌血症、粒细胞减少严重且持续的患者；粒细胞减少程度较轻和/或无症状的患者采用单药治疗可能效果良好；g）革兰氏阳性病原体已成为粒细胞减少癌症患者菌血症的常见原因；对经验性方案的反应率可能不理想，但相关死亡率较低；h）严重粒细胞减少且持续发热、血培养仍为阴性的患者发生真菌感染的风险很高；在这些患者中，可能需要使用经验性抗真菌药物。
