123
13 87
( 40% ) ( 33% ) ( 15% )
piperacillin, ceftazidime cefepime aminoglycoside
41% 35% 33% ( p=0.80 ) 87 32
36.8% 65.6% 21.9%
9.4% 11 ( 34.4% ) ( 3.4% )
( Febrile neutropenia ) ( Acute leukemia )
( Chemotherapy ) ( Taiwan )
( risk-based )
1
1960 1970
2
fluoroquinolone
( mucositis )
23-5
Piperacillin amikacin
cephalosporin
carbapenem
1,152003 8 2004 8
( febrile neutropenia)
500/cmm 38 1
3 8 . 3
500/cmm 24 500/cmm
7 2
37.5 72
( clinical response ) ( treatment failure ) 72
( infection focus )
X
piperacillin, ceftazi-
dime, cefepime carbapenem ami-
noglycoside
( Chi-square ) SPSS 12.0
37 13
8 7
70.3% 4
5 30
1 7
Port-A peripheral inserted central catheter
7 7
3 3 % ( 29/87 )
37 87
37 (18-66) 17:20 (AML:ALL:APL:biphenotype leukemia) 26:7:3:1
G-CSF 40:47
(PortA:PICC:nil) 62:5:20 4 (1 to >30)
0 (0-300) 17 (5 to >30) 20 (0 to 1500)
4 (-1 to 24) cytarabine
cytarabine cytarabine 18:19:50
ALL: acute lymphoblastic leukemia; AML: acute myeloid leukemia; APL: acute promyelocytic leukemia;
PICC: peripheral inserted central catheter
cytarabine 100mg/m
2cytarabine
1gm/m
235 ( 40% ) 13
( 1 5 % ) 7
(8%)
piperacillin
aminoglycoside 41 47% cef-
tazidime aminoglycoside 26 30
cefepime aminoglycoside 12
14% 3
( clinical response ) 87 33 ( 38% ) piperacillin-base, ceftazidime-base,
c e f e p i m e - b a s e 4 1 % 3 5 % 3 3 % ( p=0.80 )
G - C S F
1 0 0 / c m m 100/cmm
cytarabine
cytarabine cytarabine(100mg/m
2) cytarabine( 1gm/m
2)
cytarabine 57% ( 50/87 ) cytarabine 21.8% ( 19/87 ) cytarabin 20.7% ( 18/87 )
( )
( clinical response ) ( p=0.99 )
87
6.9
( ventricular tachy- c a r d i a )
( mortality ) 3.4% ( 3/87 )
32 ( 36.8% ) 3 0
65.6% ( 21/32 ) 21.9% ( 7/32 ) 9.4% ( 3/32 ) 3.0% ( 1/87 )
( Escherichia coli ) 11 ( 34.4% ) ESBL ( extended-spectrum
29 33.3% 11 37.9%
35 40.2% 13 36.1%
13 14.9% 3 23.1%
7 8.0% 0 0%
6 6.9% 3 50.0%
5 5.7% 2 40.0%
3 3.4% 1 33.3%
1 1.1% 1 100%
Piperacillin aminoglycoside
*41 (47%) 17 (41%)
Ceftazidime aminoglycoside
*26 (30%) 9 (35%)
Cefepime aminoglycoside
*12 (14%) 4 (33%)
Carbapenem 1 (1%) 1 (100%)
Glycopeptide
#+ anti G(-) antibiotics 6 (7%) 2 (33%)
Total 87 (100%) 33 (38%)
*
aminoglycoside: amikacin or gentamicin
#
glycopeptide: vancomycin or teicoplanin
beta-lactaminase)
3
ORSA ( oxacillin-resistant Staphylococcus aureus ) Candida tropicalis
fluconazole
42.9% ( 9/21 ) 0% ( 0/7 ) 43.6% ( 24/55 )
( p=0.08 )
( )
3 2
11
2 1 9
1 2
1,3,4
( febrile neutropenia ) p
0.17
50 70 29 41.4%
50 17 4 23.5%
0.14
AML 66 26 39.4%
ALL 14 6 42.9%
APL 6 0 0%
Biphenotypic 1 1 100%
G-CSF 0.71
40 16 40.0%
47 17 36.2%
0.27
57 24 42.1%
30 9 30%
0.45
20 6 30.0%
Port A 62 24 38.7%
PICC 5 3 60.0%
0.72
100 85 32 37.6
100 2 1 50%
0.99
AraC 18 7 38.9%
AraC 19 7 36.8%
AraC 50 19 38.0%
aminoglycoside: amikacin or gentamicin
#
glycopeptide: vancomycin or teicoplanin
1 Escherichia coli AML, CR HD AraC CAZ, AN
2 AML, CR HD AraC CAZ, AN then CAZ, Teico
3 Escherichia coli AML, CR HD AraC PIP, AN then IMP, Teico PIP
AN
4 Aeromonas hydrophilia APL, NR Mito, VP16, Dexan PIP, AN
5 Candida tropicalis AML, ID Ida, AraC CAZ, AN, Teico
6 Candida tropicalis AML, CR HD AraC PIP, AN then Mepem, Teico
(VT)
AML: acute myeloid leukemia; APL; acute promyelocytic leukemia; AN: amikacin; AraC: cytarabine; CAZ: ceftazidime;
CR: complete remission; Dexan: dexamethasone; HD: high dose; ID: initial diagnosis; Ida: Idarubicin; IMP: imipenem; Mito: mitox-
antrone; Mepem: meropenem; NR: Non-remission; PIP: piperacillin; Teico: teicoplanin; VP16: etoposide
1970
2
-lactam
7,8,9,10,14
piperacillin-base ceftazidime-base cefepime-base
Elting
6
i m i p e n e m c e f -
tazidime ( 5 vs 7 )
( step-down care )
1 9 9 0
( bacteremia )
11,123 0
fluoroquinolone
1
fluoroquinolone 32
( 65.6% )
( polymi-
crobial infection )
1,13cefepime ceftazidime
14
1994 1995 70
3
( 27.8% )
( 7.6% ) 1999
3 8 ( 2 0 % )
41996 2001
7 3 8
557% 32%
( 13% )
( 12% ) ciprofloxacin
( 3 5 % v s 1 3 % )
ciprofloxacin 27% ( )
( <10% )
3 candida species
fluconazole
( 9 ) C .
21 (65.6%)
Escherichia coli 11 (1ESBL)
Aeromonas sobria 2
Klebsiella pneumoniae 2
Aeromonas hydrophilia 1
Pseudomonas aeruginosa 1
Neisseria species 1
Acinetobacter species 1
Alcaligenes xylosoxidens 1
Enterobacter cloacae 1
7 (21.9%)
Staphylococcus aureus 3 (1ORSA
*)
Viridans group streptococci 2 Coagulase-negative staphylococci 1
Streptococcus pneumoniae 1
1 (3.0%)
Bacteroides species 1
3 (9.3%)
Candida albicans 1
Candida tropicalis 2
#Total 32 (100%)
30 1 1
ciprofloxacin 3 27
#
*
ORSA oxacillin-resistant Staphylococcus aureus 32
9 12
*21
0 11 11
*
3
tropicalis
5 7
1,15C. tro-
picalis
( c l i n i c a l response )
1,7-10
5-7
6,718-33%
3 8 % 4
3
5-7
( blood stream infection ) 2 0 - 35%
13
g l y - copeptide vancomycin teicoplanin
1 , 1 6
7 3
( morbidity )
18
2 0 0 2 ( IDSA )
( monotherapy ) ceftazidime, cefepime carbapenem ( combined therapy ) piperacillin, ceftazidime, cefepime carbapenem
aminoglycoside
glycopeptide
1
2 0 0 5
17
cefepime, cefpirome, piperacillin-tazobac-
tam carbapenem aminoglyco-
side ceftazidime
ceftazidime piperacillin aminoglycoside
piperacillin+aminogly- coside ceftazidime aminoglycoside ce- fepime aminoglycoside
piperacillin, ceftazidime cefepime aminoglycoside
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248-55.
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Febrile Neutropenia in Patients
with Acute Leukemia Following Chemotherapy A Retrospective Review
Sung-Nan Pei, Ming-Chung Wang, Eng-Yen Huang
1, Ming-Chun Ma, and Ching-Yuan Kuo
Febrile neutropenia is a common complication of cancer patients receiving chemotherapy. Empiric treat- ment with broad-spectrum parenteral antibiotics is important for high-risk patients. A retrospective study to eva- luate the infection sources, pathogens and clinical responses of current recommended antibiotics were conducted in patients with acute leukemia complicated with febrile neutropenia. There were 87 episodes of febrile neu- tropenia related with chemotherapy during Aug. 2003 to Aug. 2004. Piperacillin-, ceftazidime- and cefepime- based antibiotics were the major choices in this study. The clinical response rates were 41%, 35% and 33% re- spectively, and there were no statistic significance. There were three mortalities (3.4%) and two shock episodes (2.3%). Among 87 episodes, there were 32 culture results (36.8%) including 30 septicemias, one bronchoalveo- lar lavage and one tissue culture. Gram-negative bacilli were predominant (65.6%) and Escherichia coli was the leading pathogen (34%). Seven gram-positive bacteremia episodes (21.9%) occurred without shock or mortali- ty. Three candida species were isolated including two fatal Candida tropicalis candidemia and one invasive esophageal C. albicans. Our data showed that, for patients with febrile neutropenia in our hospital, there is no statistically significant difference in the response to piperacillin-, ceftazidime-, and cefepime-based empirical an- tibiotics regimens. ( J Intern Med Taiwan 2006; 17: 106-113 )
Division of Hematology/Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
1
