Roguin A, Kasis I, Ben-Arush M W, Sharon R, Berant M
Pediatric Hematology-Oncology Unit, Rambam Medical Center, Technion Faculty of Medicine, Haifa, Israel.
Pediatr Hematol Oncol. 1996 Nov-Dec;13(6):503-10. doi: 10.3109/08880019609030865.
Treatment of episodes of fever and neutropenia in pediatric hematology-oncology patients includes hospitalization and administration of intravenous antibiotics until the patient is afebrile and no longer neutropenic. The present analysis characterizes retrospectively febrile episodes in neutropenic pediatric hematology-oncology patients with regard to frequency of documented infections, organisms associated with these infections, efficacy of a standardized antibiotic regimen, and safety of early antibiotic discontinuation under defined conditions. A total of 149 pediatric febrile neutropenic episodes were identified during a 4-year period between 1990 and 1994. These occurred in 47 male and 19 female patients, of a mean age of 7.6 years (range 0.5-15). The most frequent diagnoses were leukemia (41% of patients), lymphoma (21%), rhabdomyosarcoma (7%), soft tissue sarcoma (5%), Ewing's sarcoma (5%), and osteosarcoma (4%). Infection was certain in 36% of febrile episodes, probable in 14%, and not determined in 50%. Patients with severe neutropenia (absolute neutrophil count < 100) had a slightly, although not significantly higher incidence of documented and probable infection (57%). Patients with solid tumor had documented infection in 40% of their febrile episodes, and the detection rate in the children with leukemia was 31% (P < .20) Blood cultures were positive in 21 (14%) of 149 episodes. Staphylococci (both coagulase-negative and coagulase-positive strains) and Pseudomonas were the organisms most frequently isolated (six episodes each). Mouth and throat (11), lungs (10), and skin (10) were the next most frequent sites of localized infection. Initial treatment consisted of piperacillin and amikacin or of vancomycin and amikacin when the source of fever was thought to be an infected central line catheter, with addition of amphotericin B by the seventh day of treatment when fever with neutropenia persisted or upon clinical suspicion of underlying fungal infection. There was a single fatality, of a patient with Burkitt's lymphoma. Antibiotics were discontinued when initial blood cultures had no growth after at least 48 hours and no source of infection was found, the blood count was improving, and if the patient became afebrile and clinically well. No patient needed readmission during the fortnight that followed discontinuation of antimicrobial therapy. Patients with negative blood cultures under defined conditions, as described above, could safely be discharged early, thus shortening the duration of intravenous antibiotic therapy and hospital stay.
小儿血液肿瘤患者发热伴中性粒细胞减少症发作的治疗包括住院及静脉输注抗生素，直至患者退热且不再中性粒细胞减少。本分析回顾性描述了中性粒细胞减少的小儿血液肿瘤患者发热发作的情况，涉及记录的感染频率、与这些感染相关的病原体、标准化抗生素方案的疗效以及在特定条件下早期停用抗生素的安全性。在1990年至1994年的4年期间，共识别出149例小儿发热性中性粒细胞减少症发作。这些发作发生在47例男性和19例女性患者中，平均年龄为7.6岁（范围0.5 - 15岁）。最常见的诊断为白血病（占患者的41%）、淋巴瘤（21%）、横纹肌肉瘤（7%）、软组织肉瘤（5%）、尤因肉瘤（5%）和骨肉瘤（4%）。36%的发热发作确定有感染，14%可能有感染，50%未确定。严重中性粒细胞减少（绝对中性粒细胞计数<100）的患者记录的和可能的感染发生率略高（57%），但无显著差异。实体瘤患者40%的发热发作有记录的感染，白血病患儿的检出率为31%（P <.20）。149次发作中有21次（14%）血培养阳性。葡萄球菌（凝固酶阴性和凝固酶阳性菌株）和铜绿假单胞菌是最常分离出的病原体（各6次发作）。口腔和咽喉（11次）、肺部（10次）和皮肤（10次）是接下来最常见的局部感染部位。初始治疗包括哌拉西林和阿米卡星，或当发热源被认为是感染的中心静脉导管时使用万古霉素和阿米卡星，当发热伴中性粒细胞减少持续或临床怀疑有潜在真菌感染时，在治疗第7天加用两性霉素B。有1例伯基特淋巴瘤患者死亡。当最初的血培养至少48小时无生长且未发现感染源、血细胞计数改善、患者退热且临床状况良好时，停用抗生素。在停用抗菌治疗后的两周内，没有患者需要再次入院。如上所述，在特定条件下血培养阴性的患者可以安全地提前出院，从而缩短静脉抗生素治疗的持续时间和住院时间。
