O'Hanley P, Easaw J, Rugo H, Easaw S
Department of Medicine, Stanford University, California 94305.
Am J Med. 1989 Dec;87(6):605-13. doi: 10.1016/s0002-9343(89)80391-2.
The purpose of this study was to determine the recent incidence of infection and to evaluate antimicrobial usage among adult leukemic patients undergoing chemotherapy for acute myelogenous leukemia (AML) and acute lymphoblastic leukemia (ALL) at Stanford University Hospital.
The records of 142 adult patients from a consecutive series of 226 induction or consolidation/maintenance chemotherapy courses for AML or ALL between 1982 to 1986 were reviewed retrospectively. Data were analyzed to compare the infectious disease complications and antimicrobial usage for patients receiving identical chemotherapy for a specific phase of leukemia treatment. Evaluation for each chemotherapy course included assessments for the following: compliance with criteria for initiating antibiotics, incidence of infection that was documented by culture or clinical criteria, predictive value of surveillance cultures, incidence of superinfection, survival outcomes, antimicrobial usage, antibiotic-related adverse effects, and cost for antibiotics and diagnostic studies.
Antimicrobials were employed in 190 (84%) of 226 chemotherapy courses. Broad-spectrum antibiotics were regularly begun within the first five days of admission and they were continued for an average of 3.5 weeks until the granulocyte count was greater than 1,000/microL after discontinuation of chemotherapy. There were no differences in the types of infection or outcomes among the patient groups. There was only a 37% rate of documented infections by culture or clinical signs among these patients during their entire hospital stay. Bacterial infections, especially those caused by coagulase-negative staphylococci in patients with Hickman catheters, accounted for 93% of the episodes. Viral and fungal infections accounted for 4% and 3% of documented cases, respectively, and occurred more than 10 days after the institution of broad-spectrum antibiotic therapy. A total of 922 different antimicrobials were employed in 190 courses (average 4.9 per course). The rationale for excessive usage and multiple changes was a persistent or intermittent fever, rather than documented infection(s). This practice led to usage of more broad-spectrum and expensive antibiotics. Further analyses indicate that the greater number of antibiotics employed correlated with apparent increased toxicity, especially renal and hepatic adverse reactions. These toxicities were associated with higher rates of fatal outcomes, i.e., 12 (39%) of 31 patients died with antibiotic-associated hepatic and/or renal insufficiency, compared with 12 (7.5%) of 159 patients who died without antibiotic-associated organ damage.
Excessive antibiotic usage and multiple antibiotic changes among adult leukemic patients undergoing chemotherapy appear to increase the risks of adverse hepatic and renal effects and death. Furthermore, this practice leads to use of more broad-spectrum and expensive antibiotics...
本研究旨在确定斯坦福大学医院接受急性髓系白血病（AML）和急性淋巴细胞白血病（ALL）化疗的成年白血病患者近期的感染发生率，并评估抗菌药物的使用情况。
回顾性分析了1982年至1986年间连续进行的226例AML或ALL诱导或巩固/维持化疗疗程中142例成年患者的记录。分析数据以比较白血病治疗特定阶段接受相同化疗的患者的感染性疾病并发症和抗菌药物使用情况。对每个化疗疗程的评估包括以下方面：抗生素起始标准的依从性、通过培养或临床标准记录的感染发生率、监测培养的预测价值、二重感染发生率、生存结局、抗菌药物使用情况、抗生素相关不良反应以及抗生素和诊断研究的费用。
226个化疗疗程中有190个（84%）使用了抗菌药物。广谱抗生素通常在入院后的头五天内开始使用，并持续平均3.5周，直到化疗停药后粒细胞计数大于1000/μL。患者组之间的感染类型或结局没有差异。在这些患者的整个住院期间，通过培养或临床体征记录的感染率仅为37%。细菌感染，尤其是带有希克曼导管的患者中由凝固酶阴性葡萄球菌引起的感染，占感染事件的93%。病毒和真菌感染分别占记录病例的4%和3%，且发生在广谱抗生素治疗开始10天之后。190个疗程中共使用了922种不同的抗菌药物（平均每个疗程4.9种）。过度使用和多次更换抗菌药物的理由是持续或间歇性发热，而非记录的感染。这种做法导致使用了更多的广谱和昂贵抗生素。进一步分析表明，使用的抗生素数量越多，毒性明显增加，尤其是肾和肝不良反应。这些毒性与更高的死亡率相关，即31例患者中有12例（39%）死于抗生素相关的肝和/或肾功能不全，而159例未发生抗生素相关器官损害的患者中有12例（7.5%）死亡。
接受化疗的成年白血病患者中过度使用抗生素和多次更换抗生素似乎会增加肝和肾不良反应及死亡的风险。此外，这种做法导致使用更多的广谱和昂贵抗生素……
