Akut lösemili çocuklarda nötropenik ateş ataklarının değerlendirilmesi
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Dosyalar
Tarih
2021
Yazarlar
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Yayıncı
Necmettin Erbakan Üniversitesi Meram Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Hematolojik malignite hastalarında gelişen nötropenik ateş, hastanede yatış gerektiren ve ölümle sonuçlanabilen en sık komplikasyondur. Nedeni açıklanana kadar enfeksiyona bağlı olduğu kabul edilir. Bu nedenle multidisipliner yaklaşım gerektirmekte ve medikal bir acil olarak tedavi edilmektedir. Güncel tedavi yaklaşımlarıyla enfeksiyona bağlı ölüm oranları azaltılmaya çalışılmaktadır. Bu çalışmada merkezimizde takip edilen akut lösemili nötropenik ateşli çocukların klinik özelliklerinin, risk faktörlerinin, izole edilen patojenlerin dağılımının ve mortalite üzerine etkili faktörlerin retrospektif olarak araştırılması amaçlandı. Gereç-yöntem: Bu çalışmada Ocak 2010-Aralık 2019 tarihleri arasında hastanemizin hematoloji bölümüzde takip ve tedavi edilen 237 akut lösemili çocuğun 712 nötropenik ateş atağı incelendi. Hastaların yaş, cinsiyet, altta yatan hastalık, aldıkları kemoterapi, başvuru sırasındaki kan sayımı sonuçları, görüntüleme yöntemlerindeki bulgular, uygulanan antibakteriyel, antifungal ve destek tedavileri kaydedildi. Hastalardan rutin kan, idrar ve boğaz kültürü, gerektiğinde diğer steril vücut sıvılarından kültür örnekleri alındı ve mikrobiyolojik açıdan incelendi. Bulgular: Çalışmaya katılan hastaların 104'ü (%43,9) kız, 133'ü (%56,1) erkek, yaş ortalaması 7,06±4,63 yıl olarak bulundu. Hastaların hastanede yatış süreleri ortalama 15,33±16,06 gün, ortalama nötropeni süresi 8,21±7,76 gün, ortalama ateşli gün sayısı 5,01±6,45 gündü. Hasta başına düşen atak sayısı ortalama 3±2,03 olup hastaların en sık indüksiyon kemoterapisi esnasında atağa girdiği görüldü. Değerlendirilen atakların, %38,1'inde mikrobiyolojik olarak kanıtlanmış enfeksiyon, %50,8'inda klinik olarak saptanmış enfeksiyon saptandı. Klinik olarak en sık görülen enfeksiyon odağı mukozit (%30,6) ve pnömoni (%17,1) idi. Mikrobiyolojik dökümantasyonda bakteriyemi oranı %19 bulundu ve bunun %49,6'sı gram pozitif bakteri, %46,7'si gram negatif bakteri, %3,7'si fungal etkendi. Kan kültüründe en sık izole edilen bakteriler KNS (%33,3), E.Coli (%12,6) ve Klebsiella (%11,1), idrar kültüründe E.coli, boğaz kültüründe E.coli ve Klebsiella olarak görüldü. Ataklardaki fungal pnömoni oranı %27,3 olup, %51'i yüksek risk lösemi, %35,8'si AML, %47,2'si indüksiyon tedavisi almaktaydı. Fungal pnömonili hastaların mortalitesi %11,3 bulundu. Genel mortalite ise %12,2 olup, Down sendromu, yüksek risk grubu lösemi, fungal pnömoni varlığı, yüksek CRP (>90 mg/L), düşük nötrofil sayısı (100 m³/L) ve uzamış nötropeni mortalite riskini artıran etkenler olarak değerlendirildi. Yine ölen vakalarımızın %69'u indüksiyon tedavisi almaktaydı. Sonuç: Hematolojik maligniteli hastalarda nötropenik ateş ölümcül seyredebilen bir komplikasyondur. Nötropenik ateş saptandığında enfeksiyon odağını belirlemeye yönelik mikrobiyolojik ve klinik yaklaşımların hızla ve özenle yapılması, ampirik antimikrobiyal tedavinin hızlı bir şekilde başlatılması, tedavi yanıtının izlenmesi morbidite ve mortaliteyi azaltmada önemli yaklaşımlar olacaktır. Nötropenik ateşli çocukların takip edilerek, mikroorganizma dağılımı ve antibiyotik direnç profillerinin periyodik olarak belirlenmesi gerekmektedir.
Neutropenic fever that occurs in patients with hematological malignancies is the most common complication which requires hospitalization and may result in death. It is considered to be caused by an infection until proven otherwise. It therefore requires a multidisciplinary approach and is treated as a medical emergency. Mortality rates due to infections have been tried to be reduced with current treatment approaches. In this study, it was aimed to retrospectively investigate clinical characteristics and risk factors of patients with neutropenic fever who were diagnosed with acute leukemia, as well as distribution of the isolated pathogens and factors influencing mortality. Material-method: In this study, 712 episodes of neutropenic fever in 237 children diagnosed with acute leukemia who were being followed-up and treated in department of pediatric hematology of our hospital between January 2010 and December 2019 were examined. Patients' age, gender, underlying disease, chemotherapies they were receiving, complete blood count at admission and findings in imaging studies, as well as administered antibacterial, antifungal and supportive therapies were recorded. Patients' routine blood, urine and throat cultures and, when necessary, samples from other sterile body fluids were obtained and then microbiologically examined. Results: Of the patients included in the study; 104 (43.9%) were female and 133 (56.1%) male, with a mean age of 7.06±4.63 years. Of the patients; mean duration of hospital stay was 15.33±16.06 days, mean duration of neutropenia was 8.21±7.76 days and mean number of febrile days was 5.01±6.45 days. Mean number of episodes per patient was 3±2.03 and the patients were determined to have the episodes most commonly during induction chemotherapy. Of the examined episodes; there was a microbiologically proven infection in 38.1% and clinically diagnosed infection in 50.8%. The most common clinical origin of infection was mucositis (30.6%) and pneumonia (17.1%). Rate of bacteremia was determined to be 19% in microbiological documentation, in which the agent was gram-positive bacteria in 49.6%, gram-negative bacteria in 46.7% and fungi in 3.7%. The most commonly isolated bacteria were observed to be KNS (33.3%), E. Coli (12.6%) and Klebsiella (11.1%) in blood cultures, E. Coli in urine cultures, and E. Coli and Klebsiella in throat cultures. Rate of fungal pneumonia during the episodes was 27.3% and of these; 51% were receiving chemotherapy for high-risk ALL, 35.8% for AML and 47.2% receiving induction treatment. Mortality rate of the patients with fungal pneumonia was determined to be 11.3%. Overall mortality rate, however, was 12.2%; presence of Down syndrome, high-risk leukemia and fungal pneumonia, as well as high CRP (>90 mg/L), low neutrophils count (100 m³/L) and prolonged neutropenia were found to be the factors increasing risk of mortality. Again, 69% of our deceased patients were receiving induction chemotherapy. Conclusion: Neutropenic fever is a complication in patients with hematological malignancies which may have a fatal course. When neutropenic fever is recognized, rapid and careful microbiological and clinical approaches for determination of the origin of the infection, rapid initiation of empirical antimicrobial therapy and monitoring of response to the treatment will be important approaches in reducing morbidity and mortality. Follow-up of the children with neutropenic fever and periodical determination of distribution of microorganisms and antibiotic resistence profiles are necessary.
Neutropenic fever that occurs in patients with hematological malignancies is the most common complication which requires hospitalization and may result in death. It is considered to be caused by an infection until proven otherwise. It therefore requires a multidisciplinary approach and is treated as a medical emergency. Mortality rates due to infections have been tried to be reduced with current treatment approaches. In this study, it was aimed to retrospectively investigate clinical characteristics and risk factors of patients with neutropenic fever who were diagnosed with acute leukemia, as well as distribution of the isolated pathogens and factors influencing mortality. Material-method: In this study, 712 episodes of neutropenic fever in 237 children diagnosed with acute leukemia who were being followed-up and treated in department of pediatric hematology of our hospital between January 2010 and December 2019 were examined. Patients' age, gender, underlying disease, chemotherapies they were receiving, complete blood count at admission and findings in imaging studies, as well as administered antibacterial, antifungal and supportive therapies were recorded. Patients' routine blood, urine and throat cultures and, when necessary, samples from other sterile body fluids were obtained and then microbiologically examined. Results: Of the patients included in the study; 104 (43.9%) were female and 133 (56.1%) male, with a mean age of 7.06±4.63 years. Of the patients; mean duration of hospital stay was 15.33±16.06 days, mean duration of neutropenia was 8.21±7.76 days and mean number of febrile days was 5.01±6.45 days. Mean number of episodes per patient was 3±2.03 and the patients were determined to have the episodes most commonly during induction chemotherapy. Of the examined episodes; there was a microbiologically proven infection in 38.1% and clinically diagnosed infection in 50.8%. The most common clinical origin of infection was mucositis (30.6%) and pneumonia (17.1%). Rate of bacteremia was determined to be 19% in microbiological documentation, in which the agent was gram-positive bacteria in 49.6%, gram-negative bacteria in 46.7% and fungi in 3.7%. The most commonly isolated bacteria were observed to be KNS (33.3%), E. Coli (12.6%) and Klebsiella (11.1%) in blood cultures, E. Coli in urine cultures, and E. Coli and Klebsiella in throat cultures. Rate of fungal pneumonia during the episodes was 27.3% and of these; 51% were receiving chemotherapy for high-risk ALL, 35.8% for AML and 47.2% receiving induction treatment. Mortality rate of the patients with fungal pneumonia was determined to be 11.3%. Overall mortality rate, however, was 12.2%; presence of Down syndrome, high-risk leukemia and fungal pneumonia, as well as high CRP (>90 mg/L), low neutrophils count (100 m³/L) and prolonged neutropenia were found to be the factors increasing risk of mortality. Again, 69% of our deceased patients were receiving induction chemotherapy. Conclusion: Neutropenic fever is a complication in patients with hematological malignancies which may have a fatal course. When neutropenic fever is recognized, rapid and careful microbiological and clinical approaches for determination of the origin of the infection, rapid initiation of empirical antimicrobial therapy and monitoring of response to the treatment will be important approaches in reducing morbidity and mortality. Follow-up of the children with neutropenic fever and periodical determination of distribution of microorganisms and antibiotic resistence profiles are necessary.
Açıklama
Anahtar Kelimeler
Çocukluk çağı, Akut lösemileri, Nötropeni, Ateş
Kaynak
WoS Q Değeri
Scopus Q Değeri
Cilt
Sayı
Künye
Özyalvaç, B. (2021). Akut lösemili çocuklarda nötropenik ateş ataklarının değerlendirilmesi. (Yayınlanmamış tıpta uzmanlık tezi) Necmettin Erbakan Üniversitesi, Meram Tıp Fakültesi Dahili Tıp Bilimleri Bölümü Çocuk Sağlığı ve Hastalıkları Anabilim Dalı, Konya.
