Nötropenik Ateşli Hastaya Yaklaşım
Özet
Nötropenik ateş, immunsupresif tedaviler sonucu kemik iliği süpresyonu gelişen maligniteli hastalarda mortalite riski yüksek, acil yaklaşım gerektiren klinik bir tablodur. Mutlak nötrofil sayısının 500 mm3’ün altında olması nötropeni, vücut sıcaklığının 38,3°C’yi aşması veya bir saatten uzun süre 38°C’nin üzerinde seyretmesi ise nötropenik ateş olarak tanımlanır. Bu hastalarda saptanan ateş, başka bir sebep bulunana kadar enfeksiyon kabul edilmeli ve odak araştırmasına yönelik tetkiklerin ardından ilk bir saat içinde intravenöz geniş spektrumlu ampirik antibiyotik tedavisi başlanmalıdır. Hastaların yönetiminde MASCC, Talcott veya CISNE skorlama sistemleri kullanılarak risk sınıflandırması yapılır. Düşük riskli hastalar, oral kinolon ve amoksisilin-klavulanat kombinasyonuyla ayaktan takip edilebilirken; yüksek riskli hastaların yatırılarak anti-pseudomal etkili antibiyotiklerle tedavi edilmesi gerekir. Beş günden uzun süren dirençli ateş durumunda ise ölümcül seyredebilen mantar enfeksiyonlarına karşı antifungal tedavi düşünülmelidir.
Febrile neutropenia is a high-mortality medical emergency requiring immediate intervention in cancer patients experiencing bone marrow suppression due to immunosuppressive therapies. It is defined as an absolute neutrophil count below 500 mm3 combined with a body temperature exceeding 38.3°C or sustained above 38°C for more than one hour. Fever in these patients must be treated as an infection until proven otherwise, necessitating immediate diagnostic workups followed by the administration of intravenous broad-spectrum empirical antibiotics within the first hour. Patient management relies on risk stratification scoring systems such as MASCC, Talcott, or CISNE. Low-risk patients can be managed in an outpatient setting using a combination of oral quinolones and amoxicillin-clavulanate, whereas high-risk patients require hospitalization and empirical intravenous antibiotics with anti-pseudomonal activity. If a prolonged neutropenic fever persists beyond five days despite appropriate antibiotic coverage, empirical antifungal therapy must be initiated to combat potentially fatal fungal infections.
Referanslar
Hızel, K. Tunçcan, ÖG. (2016). Nötropenik Ateş. Meral Gülhan, Ülkü Yılmaz (Ed.), Akciğer Kanserinde Destek Tedavisi içinde (s.239-257). İstanbul: Probiz Ltd. Şti.
Freifeld, AG, Bow, EJ, Sepkowitz KA. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 2011; 52 (4), e56-e93.
UptoDate (2022). Treatment of neutropenic fever syndromes in adults with hematologic malignancies and hematopoietic cell transplant recipients (high-risk patients). (03/02/2022 tarihinde https://www.uptodate.com/contents/treatment-of-neutropenic-fever-syndromes-in-adults-with-hematologic-malignancies-and-hematopoietic-cell-transplant-recipients-high-risk-patients adresinden ulaşılmıştır.)
Klastersky, J. Management of fever in neutropenic patients with different risks of complications. Clinical Infectious Diseases, 2004; 39 (Suppl 1), 32-37.
Carmona-Bayonas, A, Jiménez-Fonseca, P, Virizuela Echaburu, J. Prediction of serious complications in patients with seemingly stable febrile neutropenia: validation of the Clinical Index of Stable Febrile Neutropenia in a prospective cohort of patients from the FINITE study. Journal of Clinical Oncology, 2015; 33 (5), 465-471.
Kuderer, NM, Dale, DC, Crawford, J. Mortality, morbidity, and cost associated with febrile neutropenia in adult cancer patients. Cancer, 2006; 06 (10), 2258-2266.
Legrand, M, Max, A, Peigne, V. Survival in neutropenic patients with severe sepsis or septic shock. Critical Care Medicine, 2012; 40 (1), 43-49.
Kayaaslan, Bircan. Febril Nötropenik Hasta Takibinde Kılavuzlar: IDSA ve ECIL Karşılaştırması. Flora, 2016; 21 (1) : 1-9.
Taplitz, RA, Kennedy, EB, Bow, EJ. Outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology and Infectious Diseases Society of America Clinical Practice Guideline Update. Journal of Clinical Oncology, 2018; 36 (14), 1443-1453.
Klastersky, J, Paesmans M, Rubenstein, EB. The Multinational Association for Supportive Care in Cancer risk index: a multinational scoring system for identifying low-risk febrile neutropenic cancer patients. Journal of Clinical Oncology, 2000; 18 (16), 3038-3051.
Flowers CR, Seidenfeld J, Bow EJ. Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology, 2013; 31(6), 794-810.
Talcott, JA, Siegel, RD, Finberg, R. Risk assessment in cancer patients with fever and neutropenia: a prospective, two-center validation of a prediction rule. Journal of Clinical Oncology, 1992; 10 (2), 316-322.
Nucci, M. How I treat febrile neutropenia. Mediterranean Journal of Hematology and Infectious Diseases, 2021; 13 (1), e2021025.
Averbuch, D, Orasch, C, Cordonnier, C. European guidelines for empirical antibacterial therapy for febrile neutropenic patients in the era of growing resistance: summary of the 2011 4th European Conference on Infections in Leukemia. Haematologica, 2013; 98 (12), 1826.
Cometta, A, Kern, WV, De Bock, R. Vancomycin versus placebo for treating persistent fever in patients with neutropenic cancer receiving piperacillin-tazobactam monotherapy. Clinical Infectious Diseases, 2003; 37 (3), 382-389.
Pagano, L, Caira, M, Candoni, A. The epidemiology of fungal infections in patients with hematologic malignancies: the SEIFEM-2004 study. Haematologica, 2006; 91 (8), 1068-1075.
Gerson, SL, Talbot, GH, Hurwitz, S. Prolonged granulocytopenia: the major risk factor for invasive pulmonary aspergillosis in patients with acute leukemia. Annals of Internal Medicine, 1984; 100 (3), 345-351.
Maertens, J, Theunissen, K, Verhoef, G. Galactomannan and computed tomography–based preemptive antifungal therapy in neutropenic patients at high risk for invasive fungal infection: a prospective feasibility study. Clinical Infectious Diseases, 2005; 41 (9), 1242-1250.
Senn, L, Robinson, JO, Schmidt, S. 1, 3-β-D-glucan antigenemia for early diagnosis of invasive fungal infections in neutropenic patients with acute leukemia. Clinical Infectious Diseases, 2008; 46 (6), 878-885.
