Browne M J, Potter D, Gress J, Cotton D, Hiemenz J, Thaler M, Hathorn J, Brower S, Gill V, Glatstein E
Infectious Disease Service, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892.
J Clin Oncol. 1990 Feb;8(2):222-9. doi: 10.1200/JCO.1990.8.2.222.
Twenty-four cancer patients with diffuse interstitial pneumonitis (DIP) were randomized to undergo an open lung biopsy (OLB) within 8 hours of presentation (12 patients) or to receive empiric antimicrobial therapy (ET) with trimethoprim-sulfamethoxazole (TMP-SMX) erythromycin for a minimum of 4 days (12 patients). Patients whose condition deteriorated underwent an OLB on day 4. Eight of 12 patients (67%) having OLB survived versus 10 of 12 (83%) receiving ET (P = .64). Morbidity occurred in nine of 12 (75%) having OLB versus eight of 12 (67%) receiving ET (P = 1.0). Concurrently, there were 14 additional cancer patients with DIP who were not randomized (nine refused, three had a coagulopathy contraindicating surgery, two were excluded by primary care physicians) and who were comparable demographically to the randomized group. Two received OLB and 12 ET. Combining the randomized and nonrandomized groups, eight of 14 (57%) having an initial OLB survived versus 18 of 24 (75%) of ET-treated patients (P2 = .19). Results of the OLB were seven Pneumocystis carinii pneumonia (PCP), five nonspecific pneumonitis (NSP), one cytomegalovirus, and one lymphoma. Results of OLB led to discontinuation of antibiotics in three patients. Of the 24 ET patients, eight failed to improve by day 4 and had an OLB. Results were two NSP, two PCP, two cancer, one blastomycosis, and one Candida pneumonia. Complications were seen in 10 of 14 (72%) initial OLB patients versus 14 of 24 (58%) patients on the ET arm (P = .65). When the complication rate between patients receiving only empiric antibiotics was compared with all patients having an OLB (initially or on day 4), the difference was greater in patients undergoing OLB (37% v 72%, respectively) (P2 = .14). ET with TMP-SMX plus erythromycin and broad spectrum antibiotics in granulocytopenic patients appeared to be as successful and potentially less toxic than an OLB in this study. Although the number of patients in this study was small, these data suggest that a trial of empiric antibiotic management may be reasonable in cancer patients presenting with DIP, especially if they are nonneutropenic.
24例患有弥漫性间质性肺炎（DIP）的癌症患者被随机分为两组，一组在就诊后8小时内接受开胸肺活检（OLB）（12例患者），另一组接受经验性抗菌治疗（ET），使用甲氧苄啶 - 磺胺甲恶唑（TMP - SMX）和红霉素，至少治疗4天（12例患者）。病情恶化的患者在第4天接受OLB。接受OLB的12例患者中有8例（67%）存活，而接受ET的12例患者中有10例（83%）存活（P = 0.64）。接受OLB的12例患者中有9例（75%）出现并发症，接受ET的12例患者中有8例（67%）出现并发症（P = 1.0）。同时，还有14例患有DIP的癌症患者未被随机分组（9例拒绝，3例有凝血功能障碍禁忌手术，2例被初级保健医生排除），他们在人口统计学特征上与随机分组的患者相似。2例接受OLB，12例接受ET。将随机分组和未随机分组的患者合并后，最初接受OLB的14例患者中有8例（57%）存活，而接受ET治疗的24例患者中有18例（75%）存活（P2 = 0.19）。OLB的结果为7例卡氏肺孢子虫肺炎（PCP）、5例非特异性肺炎（NSP）、1例巨细胞病毒感染和1例淋巴瘤。OLB的结果导致3例患者停用抗生素。在24例接受ET的患者中，8例在第4天病情未改善并接受了OLB。结果为2例NSP、2例PCP、2例癌症、1例芽生菌病和1例念珠菌肺炎。14例最初接受OLB的患者中有10例（72%）出现并发症，接受ET治疗的24例患者中有14例（58%）出现并发症（P = 0.65）。当仅接受经验性抗生素治疗的患者与所有接受OLB（最初或第4天）的患者的并发症发生率进行比较时，接受OLB的患者差异更大（分别为37%对72%）（P2 = 0.14）。在本研究中，对于粒细胞减少的患者，使用TMP - SMX加红霉素进行ET和使用广谱抗生素似乎与OLB一样成功，且潜在毒性可能更小。尽管本研究中的患者数量较少，但这些数据表明，对于出现DIP的癌症患者，尤其是非中性粒细胞减少的患者，进行经验性抗生素治疗试验可能是合理的。
