BLOODSTREAM INFECTIONS IN FEBRILE NEUTROPENIC PATIENTS: BACTERIAL SPECTRUM AND ANTIMICROBIAL SUSCEPTIBILITY PATTERN
Abstract
Background: Bacterial infections are the major cause of morbidity and mortality among neutropenic patients. Prompt administration of empiric antimicrobial therapy for febrile neutropenic patients is considered vital. Before putting neutropenic patients on empiric antimicrobial regimens, it is essential to be aware of the spectrum of locally prevalent pathogens and their susceptibility pattern. Methods: We studied the bacterial spectrum and antimicrobial susceptibility pattern of organisms causing bloodstream infections in febrile neutropenic patients in Armed Forces Bone Marrow Transplant Centre, Rawalpindi and the Department of Oncology, Combined Military Hospital, Rawalpindi over a period of nine months from January to September 2002. Results: Blood specimens for culture and susceptibility testing were collected from 158 febrile patients with neutropenia. Eighty-three organisms were isolated from 60 patients. Thirty-six (43%) isolates were Gram-positive cocci and forty-seven (57%) were Gram-negative rods. Among the Gram-positive cocci, coagulase negative staphylococci (CoNS) were the predominant pathogens (26%), followed by Staphylococcus aureus (8%). Among Gram-negative rods, Escherichia coliwas the predominant isolate (13%) followed by Klebsiella pneumoniae (10%), Acinetobacter johnsonii (10%) and Pseudomonas aeruginosa (7%). Nine specimens yielded polymicrobial growth. Forty percent of Staphylococcus aureus and 55% of CoNS were resistant to methicillin. All the Gram-positive isolates were susceptible to vancomycin and teicoplanin. Among the Gram-negative rods, there was 100% resistance to ampicillin, 65% to gentamicin, 47% to amikacin and 66% to third generation cephalosporins. All the gram-negative isolates were susceptible to imipenem. Conclusion: The spectrum of isolates among febrile neutropenic patients in our population appears to be shifting towards Gram-positive microorganisms. Due to increasing levels of drug resistance among the isolates, a glycopeptide in combination with a carbapenem would be a prudent choice as empiric therapy in high-risk cases.Keywords: Neutropenia; infection; fever; empiric therapy; Pakistan.References
Pizzo PA. Fever in immunocompromised patients. N Engl J Med 1999; 341: 893-900.
Donowitz GR, Maki DG, Crnich CJ, Pappas PG, Rolston KVI. Infections in the neutropenic patient – new views of an old problem. Hematology (Am Soc Hematol Edu Program) 2001; 113-39.
Hughes WT, Armstrong D, Bodley GP, Bow EJ, Brown AE, Calandra T, et al. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Infectious Diseases Society of America. Clin Infect Dis 2002; 34: 730-51.
Giamarellou H, Bassaris HP, Petrikkos G, Busch W, Voulgarelis M, Antoniadou A, et al. Monotherapy with intravenous followed by high-dose ciprofloxacin versus combination therapy with ceftazidime plus amikacin as initial empiric therapy for granulocytopenic patients with fever. Antimicrob Agents Chemother 2000; 44: 3264-71.
Pizzo PA. Management of fever in patients with cancer and treatment-induced neutropenia. N Engl J Med 1993; 328: 1323-32.
Engels EA, Ellis CA, Supran SE, Schmid CH, Barza M, Schenkein DP, et al. Early infection in bone marrow transplantation: quantitative study of clinical factors that affect risk. Clin Infect Dis 1999; 28: 256-66.
Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions of nosocomial infections. Am J Infect Control 1988; 16:128-40.
Ferraro MJ, Craig WA, Dudley MN, Eliopoulos GM, Hecht DW, Hindler J, et al. Performance standards for antimicrobial disk susceptibility tests. 7th ed. Approved Standard M2-A7. Wayne, PA: National Committee for Clinical Laboratory Standards; 2000.
Zinner SH. Changing epidemiology of infections in patients with neutropenia and cancer: emphasis on gram-positive and resistant bacteria. Clin Infect Dis 1999; 29: 490-4.
Collin BA, Leather HL, Wingard JR, Ramphal R. Evolution, incidence, and susceptibility of bacterial bloodstream isolates from 519 bone marrow transplant patients. Clin Infect Dis 2001; 33: 947-53.
Seifart H, Cornely O, Seggewiss K, Decker M, Stefanik D, Wisplinghoff H, et al. Bloodstream infection in neutropenic cancer patients related to short-term nontunnelled catheters determined by quantitative blood cultures, differential time to positivity, and molecular epidemiological typing with pulsed-field gel electrophoresis. J Clin Microbiol 2003; 41: 118-23.
Singh N, Paterson DL, Chang FY, Gayowski T, Squier C, Wagener MM, et al. Methicillin-resistant Staphylococcus aureus: the other emerging resistant Gram-positive coccus among liver transplant recipients. Clin Infect Dis 2000; 30: 322-7.
Karamat KA, Tariq TM, Hanan A, Siddiqi MS, Butt T, Anwar M, et al. Bacterial infections in neutropenic cancer patients. Pak J Pathol 1998; 9 (1): 38-43.
Siddiqui SA, Hossain M. Neutropenia and sepsis - experience in acute myeloid leukemia. Pak Armed Forces Med J 1998; 48: 72-7.
Burney IA, Farooqui BJ, Siddiqui T, Khurshid M. The spectrum of bacterial infections in febrile neutropenic patients: effect on empiric antibiotic therapy. J Pak Med Assoc 1998; 48: 364-7.
Winston DJ, Lazarus HM, Beveridge RA, Hathorn JW, Gucalp R, Ramphal R, et al. Randomized double-blind multicenter trial comparing clinafloxacin with imipenem as empirical monotherapy for febrile granulocytopenic patients. Clin Infect Dis 2001; 32: 381-90.
Del Favero A, Menichetti F, Martino P, Bucaneve G, Micozzi A, Gentile G, et al. A multicenter, double-blind, placebo-controlled trial comparing piperacillin-tazobactam with and without amikacin as empiric therapy for febrile neutropenia. Clin Infect Dis 2001; 33: 1295-1301.
Entenza JM, Que YA, Vouillamoz J, Glauser MP, Moreillon P. Efficacies of moxifloxacin, ciprofloxacin, and vancomycin against experimental endocarditis due to methicillin-resistant Staphylococcus aureus expressing various degrees of ciprofloxacin resistance. Antimicrob Agents Chemother 2001; 45: 3076-83.
Freifeld A, Marchigiani D, Walsh T, Chanock S, Lewis L, Hiemenz S, et al. A double-blind comparison of empirical oral and intravenous antibiotic therapy for low-risk febrile patients with neutropenia during cancer chemotherapy. N Engl J Med 1999; 341: 305-11.
Downloads
Issue
Section
License
Journal of Ayub Medical College, Abbottabad is an OPEN ACCESS JOURNAL which means that all content is FREELY available without charge to all users whether registered with the journal or not. The work published by J Ayub Med Coll Abbottabad is licensed and distributed under the creative commons License CC BY ND Attribution-NoDerivs. Material printed in this journal is OPEN to access, and are FREE for use in academic and research work with proper citation. J Ayub Med Coll Abbottabad accepts only original material for publication with the understanding that except for abstracts, no part of the data has been published or will be submitted for publication elsewhere before appearing in J Ayub Med Coll Abbottabad. The Editorial Board of J Ayub Med Coll Abbottabad makes every effort to ensure the accuracy and authenticity of material printed in J Ayub Med Coll Abbottabad. However, conclusions and statements expressed are views of the authors and do not reflect the opinion/policy of J Ayub Med Coll Abbottabad or the Editorial Board.
USERS are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles, or use them for any other lawful purpose, without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open access.
AUTHORS retain the rights of free downloading/unlimited e-print of full text and sharing/disseminating the article without any restriction, by any means including twitter, scholarly collaboration networks such as ResearchGate, Academia.eu, and social media sites such as Twitter, LinkedIn, Google Scholar and any other professional or academic networking site.
