Changing aetiology, clinical features, antimicrobial resistance, and outcomes of bloodstream infection in neutropenic cancer patients

Abstract

Recent changes in the management of patients with haematological malignancies might have influenced the aetiology, characteristics, antimicrobial resistance and outcomes of bloodstream infection (BSI) during neutropenia. We compared 272 episodes of BSI in adult neutropenic patients with cancer prospectively collected from January 1991 to December 1996 (first period), when quinolone prophylaxis was used, with 283 episodes recorded from January 2006 to March 2010 (second period), when antibacterial prophylaxis was stopped. Patients in the second period were significantly older and were more likely to have graft-versus-host disease and a urinary catheter in place, whereas the presence of a central venous catheter, parenteral nutrition, corticosteroids and antifungal and quinolone prophylaxis, were more frequent in the first period. More patients in the first period had mucositis and soft-tissue infection as the origin of BSI, but an endogenous source was more common during the second. Gram-positive BSI was more frequent in the first period (64% versus 41%; p <0.001), mainly due to coagulase-negative staphylococci and viridans group streptococci. In the second period gram-negative BSI increased (28% versus 49%; p <0.001), quinolone susceptibilities were recovered, but multidrug-resistant gram-negative BSI also increased (1% versus 6%; p <0.001). Although patients in the second period were more likely to need admission to the intensive-care unit, overall case-fatality rate was similar in the two periods (19% versus 15%). The aetiology of BSI in neutropenic patients with cancer has shifted from gram-positive to gram-negative organisms. Multidrug resistance among gram-negative bacilli is emerging as a therapeutic challenge. Overall case-fatality rate remains high.

Bloodstream infections in neutropenic cancer patients: A practical update

“…29 However, this tendency has reversed again, with GN bacteria becoming more frequent than GP in many centers. [32][33][34][35][36][37][38] According to a questionnaire survey performed among hematology centers from Europe and Israel participating in the European Conference on Infections in Leukemia (ECIL) in 2011, Enterobacteriaceae were isolated in approximately 30% (range 8-56%) of the BSIs, followed by coagulase-negative staphylococci (24%, range 7-51%). 39 The GP to GN ratio was 55% to 45%, but a large variability between hospitals and countries has been noted.…”

“…Extended-spectrum b-lactamase (ESBL) producing Enterobacteriaceae, which might not be covered by the standard empirical therapy with cephalosporins or piperacillin-tazobactam, are increasing in frequency in the neutropenic cancer patients 36,37,39,47,48 The percentage of ESBL-producing K. pneumoniae strains was over 50% in several series, while it was lower for E. coli, varying between 11% and 69% in different countries, even in pediatric patients. 37,[49][50][51] For example, ESBL-producing strains accounted for the 26% of all the E. coli and K. pneumoniae isolates in neutropenic patients in a South Korean study and for approximately 40% in Italian cohorts 36,43,49,52 Carbapenem-resistant gram-negative bacteria Carbapenem-resistance among GN bacteria is rising worldwide, different resistance mechanisms underlie non-susceptibility to this class of b-lactams, and K. pneumoniae, E. coli, P. aeruginosa and A. baumannii are the most affected species.…”

“…37,[49][50][51] For example, ESBL-producing strains accounted for the 26% of all the E. coli and K. pneumoniae isolates in neutropenic patients in a South Korean study and for approximately 40% in Italian cohorts 36,43,49,52 Carbapenem-resistant gram-negative bacteria Carbapenem-resistance among GN bacteria is rising worldwide, different resistance mechanisms underlie non-susceptibility to this class of b-lactams, and K. pneumoniae, E. coli, P. aeruginosa and A. baumannii are the most affected species. 45,53 In consequence, in many countries, also cancer patients develop carbapenemresistant infections, as demonstrated by a retrospective survey performed in 52 transplant centers in Italy.…”

Etiology, clinical features and outcomes of pre-engraftment and post-engraftment bloodstream infection in hematopoietic SCT recipients

“…11 At our center, we have observed a shift toward more Gram-negative infecting organisms in neutropenic cancer patients with BSI in recent years, as well as an increase in multidrug-resistant Gram-negative bacilli over time. 12 However, current and prospective information regarding the etiology and antimicrobial resistance of BSI in the specific group of patients undergoing HSCT is scarce. 1,4,8,13 The present study was performed to determine the etiology, current clinical features and outcomes of BSI in a more recent prospective cohort of adult HSCT recipients, and to identify differences between those episodes occurring in the pre-engraftment and postengraftment periods.…”

The emerging problem of bacterial resistance in cancer patients; proceedings of a workshop held by MASCC “Neutropenia, Infection and Myelosuppression” Study Group during the MASCC annual meeting held in Berlin on 27–29 June 2013

“…The Gram-negative pathogens most frequently isolated from neutropenic patients include E. coli, Klebsiella species, other Enterobacteriaceae, P. aeruginosa, and other nonfermentative Gram-negative bacilli (NFGNB) [12,13]. Antimicrobial agents commonly used for empiric and/or targeted therapy of these infections include the extendedspectrum cephalosporins (e.g., cefepime) and the carbapenems (imipenem, meropenem, and, to a lesser extent, doripenem) and combination agents such as piperacillin/tazobactam.…”