Leone Giuseppe, Pagano Livio
Istituto di Ematologia, Università Cattolica del Sacro Cuore, Roma, Italy.
Mediterr J Hematol Infect Dis. 2018 Jul 1;10(1):e2018039. doi: 10.4084/MJHID.2018.039. eCollection 2018.
Infections remain a significant problem in myelodysplastic syndromes (MDS) in treated as well in non-treated patients and assume a particular complexity. The susceptibility to infections is due, in the absence of intensive chemotherapies, mainly to functional defects in the myeloid lineage with or without neutropenia. Furthermore, MDS includes a heterogeneous group of patients with very different prognosis, therapy and risk factors regarding survival and infections. You should distinguish risk factors related to the disease, like as neutrophils function impairment, neutropenia, unfavorable cytogenetics and bone marrow insufficiency; factors related to the patient, like as age and comorbidities, and factors related to the therapy. When the patients with MDS are submitted to intensive chemotherapy with and without hematopoietic stem cell transplantation (HSCT), they have a risk factor for infection very similar to that of patients with acute myeloid leukemia (AML), and mostly related to neutropenia. Patients with MDS treated with supportive therapy only or with demethylating agent or lenalidomide or immunosuppressive drugs should have a tailored approach. Most of the infections in MDS originate from bacteria, and the main risk factors are represented by neutropenia, thrombocytopenia, and unfavorable cytogenetics. Thus, it is reasonable to give antibacterial prophylaxis to patients who start the therapy with demethylating agents with a number of neutrophils <500 × 10/L, or with thrombocytopenia and unfavorable cytogenetics. The antifungal prophylaxis is not considered cost/benefit adequate and should be taken into consideration only when there is an antecedent fungal infection or presence of filamentous fungi in the surveillance cultures. Subjects submitted to immunosuppression with ATG+CSA have a high rate of infections, and when severely neutropenic should ideally be nursed in isolation, should be given prophylactic antibiotics and antifungals, regular mouth care including an antiseptic mouthwash.
感染在接受治疗和未接受治疗的骨髓增生异常综合征（MDS）患者中仍然是一个重大问题，且具有特殊的复杂性。在没有强化化疗的情况下，感染易感性主要归因于髓系谱系中的功能缺陷，伴或不伴中性粒细胞减少。此外，MDS包括一组预后、治疗以及生存和感染风险因素差异很大的异质性患者。应区分与疾病相关的风险因素，如中性粒细胞功能损害、中性粒细胞减少、不良细胞遗传学和骨髓功能不全；与患者相关的因素，如年龄和合并症；以及与治疗相关的因素。当MDS患者接受有或没有造血干细胞移植（HSCT）的强化化疗时，他们的感染风险因素与急性髓系白血病（AML）患者非常相似，且大多与中性粒细胞减少有关。仅接受支持性治疗、或使用去甲基化药物、来那度胺或免疫抑制药物治疗的MDS患者应采取量身定制的方法。MDS中的大多数感染源自细菌，主要风险因素为中性粒细胞减少、血小板减少和不良细胞遗传学。因此，对于开始使用去甲基化药物治疗且中性粒细胞计数<500×10⁹/L、或伴有血小板减少和不良细胞遗传学的患者，给予抗菌预防是合理的。抗真菌预防被认为成本效益不佳，仅当既往有真菌感染或监测培养中有丝状真菌存在时才应考虑。接受抗胸腺细胞球蛋白（ATG）+环孢素A（CSA）免疫抑制的患者感染率很高，当中性粒细胞严重减少时，理想情况下应隔离护理，应给予预防性抗生素和抗真菌药物，定期进行口腔护理，包括使用抗菌漱口水。
