Gea-Banacloche Juan
1Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD.
Hematology Am Soc Hematol Educ Program. 2013;2013:414-22. doi: 10.1182/asheducation-2013.1.414.
Applying the principles of evidence-based medicine to febrile neutropenia (FN) results in a more limited set of practices than expected. Hundreds of studies over the last 4 decades have produced evidence to support the following: (1) risk stratification allows the identification of a subset of patients who may be safely managed as outpatients given the right health care environment; (2) antibacterial prophylaxis for high-risk patients who remain neutropenic for ≥7 days prevents infections and decreases mortality; (3) the empirical management of febrile neutropenia with a single antipseudomonal beta-lactam results in the same outcome and less toxicity than combination therapy using aminoglycosides; (4) vancomycin should not be used routinely empirically either as part of the initial regimen or for persistent fever, but rather should be added when a pathogen that requires its use is isolated; (5) empirical antifungal therapy should be added after 4 days of persistent fever in patients at high risk for invasive fungal infection (IFI); the details of the characterization as high risk and the choice of agent remain debatable; and (6) preemptive antifungal therapy in which the initiation of antifungals is postponed and triggered by the presence, in addition to fever, of other clinical findings, computed tomography (CT) results, and serological tests for fungal infection is an acceptable strategy in a subset of patients. Many practical management questions remain unaddressed.
将循证医学原则应用于发热性中性粒细胞减少症（FN）时，所产生的实践方法比预期的要有限。在过去40年里，数百项研究已得出证据支持以下内容：（1）风险分层能够识别出在合适的医疗环境下可作为门诊患者安全管理的一部分患者；（2）对中性粒细胞减少持续≥7天的高危患者进行抗菌预防可预防感染并降低死亡率；（3）用单一抗假单胞菌β-内酰胺类药物对发热性中性粒细胞减少症进行经验性治疗与使用氨基糖苷类药物的联合治疗效果相同，但毒性更低；（4）万古霉素不应作为初始治疗方案的一部分常规经验性使用，也不应因持续发热而常规使用，而应在分离出需要使用万古霉素的病原体时添加；（5）对于有侵袭性真菌感染（IFI）高风险的患者，在持续发热4天后应添加经验性抗真菌治疗；高风险特征的细节及药物选择仍存在争议；（6）抢先抗真菌治疗是一种可接受的策略，即除发热外，根据其他临床发现、计算机断层扫描（CT）结果和真菌感染血清学检测结果来推迟并触发抗真菌药物的使用，该策略适用于一部分患者。许多实际管理问题仍未得到解决。
