Pneumonia In Neutropenic Patients Research Articles

Comparison of Clinical and Radiological Features of Aspergillus, Zygomycosis, and Fusarium Pneumonia in Neutropenic Patients

Background: Opportunistic fungal pneumonia in neutropenic patients due to hematologic malignancy or bone marrow transplant continues to rise, and the diagnosis remains challenging. We sought to compare the clinical and early radiological patterns of 3 fungi (Aspergillus, Fusarium, and zygomycosis) in this population to facilitate early diagnosis and improve choice of early empiric therapy before culture results are available. Methods: This is a retrospective chart review study conducted between January 1999 and June 2010 in neutropenic patients with fungal pneumonia. Clinical and radiological features, duration of neutropenia, underlying illness, culture results, treatment choice, and outcome were recorded for each patient. Results: Total of 74 patients with fungal pneumonia met inclusion criteria: 27 had Aspergillus, 25 had Fusarium, and 22 had zygomycosis pneumonia. The following were the findings: & Underlying diagnosis: Acute myeloid leukemia was the most common underlying diagnosis in any fungal pneumonia, present in 42 (57%) of the 74 patients. & Clinical features: Toe cellulitis was present in 34% of Fusarium pneumonia cases. Blood culture positive for the fungus in 10% of the Fusarium cases. Other clinical features were reported in similar frequencies in all types of fungal pneumonia. & Radiological patterns: In 20 (80%) of 25 cases of Fusarium, early lung nodules were multiple (92) and small with an average diameter less than or equal to 1 cm at initial computed tomography scans (size: minimum 0.1, median 0.8, maximum 2.8 cm). Sixteen (67%) of 24 cases of early nodules caused by Aspergillus and 13 (72%) of 18 cases of early nodules caused by zygomycosis had a bigger size at diagnosis (size: minimum 0.3, median 1.8, maximum 4.3 cm for Aspergillus; and minimum 0.5, median 2.1, maximum 4.5 cm for zygomycosis) (P G 0.0001) and were few in number. Fusarium lung nodules had a scattered (central and peripheral) distribution in 76% of cases. Nodules caused by Aspergillus and zygomycosis were located peripherally, in 75% and 78% of cases respectively. & Duration of neutropenia: The median duration of neutropenia was shorter with an average of 18 days (minimum, median, maximum = 1, 10, 60 days, respectively) at the time of invasive Aspergillus diagnosis in contrast to that for Fusarium with an average of 48 days (minimum, median, maximum = 7, 26, 128 days, respectively) and an average of 45 days in cases due to zygomycosis (minimum, median, maximum = 4, 28.5, 105 days, respectively) (P G 0.0001). & Initial treatment and outcome: Voriconazole was used empirically initially in 53 (72%) of the 74 patients. Mortality at 3 months for all fungi was 64%, highest for zygomycosis (67%) followed by Aspergillus (63%) and Fusarium (55%). Conclusions: Clinical and radiological patterns and duration of neutropenia provide useful clues as to the nature of the fungal pneumonia in neutropenic patients. This can help better guide the choice of the initial empiric antifungal therapy and may help improve patient outcome.

P713 Risk factor analysis of blood stream infection and pneumonia in neutropenic patients after peripheral blood stem-cell transplantation

P713 Risk factor analysis of blood stream infection and pneumonia in neutropenic patients after peripheral blood stem-cell transplantation

Risk factor analysis of blood stream infection and pneumonia in neutropenic patients after peripheral blood stem-cell transplantation

The purpose of this study was to analyse risk factors for blood stream infection (BSI) and pneumonia in neutropenic patients who have undergone peripheral blood stem-cell transplantation (PBSCT). Data were taken from the ONKO-KISS multicenter surveillance project. Infections were identified using CDC definitions (laboratory-confirmed BSI) and modified criteria for pneumonia in neutropenic patients. The multivariate analysis was performed using the Fine-Gray regression model for the cumulative incidences of the competing events 'infection', 'death' and 'end of neutropenia'. The risk factors investigated were: sex, age, underlying disease and type of transplant. From January 2000 to June 2004, a total of 1699 patients in 20 hospitals were investigated. In the multivariate analysis, male patients had a significantly higher risk of acquiring BSI than female patients (P=0.002). The risk of acquiring BSI is highest in patients with advanced acute myeloid leukaemia (AML). In the univariate and multivariate analysis, unrelated donor allogeneic transplantation constituted a risk factor for pneumonia (P=0.012). ONKO-KISS provides reference data on the incidence of pneumonia and BSI. The increased risk for BSI in males and patients with advanced AML, and the increased risk for pneumonia in unrelated donor allogeneic PBSCT patients should be targeted to prevent infections in these higher risk groups.

Niedrigdosis-CT der Lunge bei neutropenischen Patienten mit unklarem Fieber

To define the value of low-dose multislice CT in a clinical setting for early detection of pneumonia in neutropenic patients with fever of unknown origin. Thirty-five neutropenic patients suffering from fever of unknown origin with normal chest X-ray underwent unenhanced low-dose CT of the chest (120 kV, 10 eff. mAs, collimation 4 x 1 mm) using a multislice CT scanner. Axial und frontal slices with a thickness of 5 mm were calculated. If no pneumonia was found, standard antibiotics were given and a repeated examination was performed if fever continued. In case of pneumonia, antimycotic therapy was added and a follow-up CT was performed within one week. Regression or progression of pneumonia at follow-up served as evidence of pneumonia; lowering of fever within 48 h or inconspicuous follow-up CT was regarded as absence of pneumonia. Ten of 35 patients had pneumonic infiltration, which decreased or increased on follow-up CT in 3 and 6 patients, respectively. One patient revealed leucemic infiltration by bronchoalveolar lavage. Twenty-five of 35 patients had no evidence of pneumonia. Twenty of these patients were free of fever within 48 h under antibiotics; one patient died due to his basic illness. Out of 4 patients with persisting fever, 3 patients had no pneumonia on repeated examination; one patient showed disseminated micronodular infiltration. Frontal reconstructions helped to differentiate infiltration from atelectasis in 4 patients. Sensitivity and specificity for the detection of pneumonia at the first examination were 90 % and 96 %, negative predictive value was 96 %. Low-dose multislice CT should be performed in neutropenic patients having a fever of unknown origin and normal chest X-ray.

Pneumonia in neutropenic patients.

Radiologists have a special role in the management of neutropenic patients. The appropriate investigational technique, frequently targeted differential diagnosis, and the special needs of these patients, need to be understood. Early detection of a focus is the major goal in febrile neutropenic patients. As pneumonia is the most common focus, chest imaging is a special radiological task. The sensitivity of chest X-ray, especially in supine position, is known to be low; therefore, the very sensitive high-resolution CT (HRCT) became gold standard in neutropenic hosts and will probably be replaced by thin-section multislice CT (MSCT) in the near future. Costs of high-resolution CT are low in comparison to antibiotics. An infiltrate needs to be localised, so that a physician can utilise this information as a guidance for invasive procedures for further microbiological work-up. The radiological characterisation of infiltrates gives a first and rapid hint to differentiate between different sorts of infectious (typical bacterial, atypical bacterial, fungal) and non-infectious aetiologies. Follow-up investigations need careful interpretation according to disease and concomitant treatment. Due to an increased incidence of fungal infiltrates even with appropriate therapy, follow-up of an infiltrate must use further parameters in addition to lesion size. Temporary exclusion of infectious involvement of the lung with high accuracy remains of special interest for clinicians.

Bacteremic pneumonia in neutropenic patients with cancer: causes, empirical antibiotic therapy, and outcome.

Bacteremic pneumonia is a major cause of death among neutropenic patients with cancer. We analyzed the causes, empirical antibiotic therapy, and outcome of 40 consecutive cases of bacteremic pneumonia identified among 408 episodes of bacteremia in adult neutropenic patients with cancer, prospectively documented from 1986 to 1995. The most frequent causative organisms were Pseudomonas aeruginosa (17 cases), Streptococcus pneumoniae (12 cases), Escherichia coli (5 cases), and Streptococcus mitis (3 cases). Overall, P. aeruginosa and S. pneumoniae caused 72.5% of all episodes of bacteremic pneumonia, compared with 11.4% of bacteremic episodes from other sources (P< .001). Thirty patients received ceftazidime and 10 patients received imipenem as the beta-lactam component of the initial empirical treatment. All strains of P. aeruginosa were susceptible to both agents. Forty-seven percent of streptococcal strains were penicillin resistant and showed a decreased susceptibility to ceftazidime (minimum inhibitory concentration ranged from 1 to 64 microg/mL). Five patients (12.5%) were considered to have received inappropriate empirical antibiotic therapy. Attributable mortality in patients with bacteremic pneumonia was higher than in patients with bacteremia from other sources; 22 (55%) of the 40 patients with bacteremic pneumonia died, whereas 39 (10.6%) of the 368 patients with bacteremia from other sources died (P<.001). Our data suggest that bacteremic pneumonia in neutropenic cancer patients is associated with a poor outcome and that empirical antibiotic therapy for neutropenic patients with pneumonia should include agents active against both P. aeruginosa and cephalosporin-resistant streptococci.

Early detection of pneumonia in febrile neutropenic patients: use of thin-section CT.

The purpose of this study was to evaluate the usefulness of thin-section CT for early detection of pneumonia in neutropenic patients with an unknown site of infection and normal or nonspecific findings on chest radiographs. Eighty-seven patients with febrile neutropenia that persisted for more than 2 days despite empiric antibiotic treatment underwent 146 prospective examinations. If findings on chest radiographs were normal (n = 126) or nonspecific (n = 20), thin-section CT (1-mm collimation, 10-mm increment) was done. If thin-section CT scans showed opacities, bronchoalveolar lavage was recommended. Findings on chest radiographs were nonspecific for pneumonia in 20 (14%) of 146 cases, and CT findings in those cases were suggestive of pneumonia. Microorganisms were detected in 11 of those 20 cases. Seven of the 11 cases were not optimally treated before CT diagnosis, the other four were sufficiently treated. Findings on chest radiographs and thin-section CT scans were normal in 56 (38%) of 146 cases. In 70 (48%) of 146 cases, findings on chest radiographs were normal, whereas findings on thin-section CT scans were suggestive of pneumonia. Microorganisms were detected in 30 of the 70 cases. Nineteen of 30 cases were not optimally treated before CT, whereas the other 11 cases were sufficiently treated before CT. In 22 (31%) of these 70 cases, an opacity was observed on the chest radiograph during the 7 days after the CT study. Only three (5%) of 56 pneumonias occurred during the first 7 days after thin-section CT studies with normal findings (p < .005). Additional risk factors for pneumonia occurring later that were detectable on chest radiographs were poorly defined nodules (p < .05), consolidation (p < .05), and younger age (p < .05). Thin-section CT scans show findings suggestive of pneumonia about 5 days earlier than chest radiographs show suggestive findings. When thin-section CT scans show findings suggestive of pneumonia, the probability of pneumonia being detected on chest radiographs during the 7-day follow-up is 31%, whereas the probability is only 5% when the findings on the prior thin-section CT scan were normal (p < .005). All neutropenic patients with fever of unknown origin and normal findings on chest radiographs should be examined with thin-section CT.

Aspergillus fumigatus Pneumonia in Neutropenic Patients Receiving Fluconazole for Infection Due to Candida Species: Is Amphotericin B Combined with Fluconazole the Appropriate Answer?

Journal Article Aspergillus fumigatus Pneumonia in Neutropenic Patients Receiving Fluconazole for Infection Due to Candida Species: Is Amphotericin B Combined with Fluconazole the Appropriate Answer? Get access Stephan Pahls, Stephan Pahls Department of Medicine, Universitätsspital, Zürich, Switzerland Search for other works by this author on: Oxford Academic PubMed Google Scholar Andreas Schaffner Andreas Schaffner Department of Medicine, Universitätsspital, Zürich, Switzerland Reprints or correspondence: Dr. Andreas Schaffner, Medizinische Klinik, Universitätsspital Zürich, Ramistrasse 100, Room AA23, CH-8091 Zürich, Switzerland. Search for other works by this author on: Oxford Academic PubMed Google Scholar Clinical Infectious Diseases, Volume 18, Issue 3, March 1994, Pages 484–485, https://doi.org/10.1093/clinids/18.3.484 Published: 01 March 1994

Quinolones in the Treatment of Community-Acquired Pneumonia in Neutropenic Patients

Quinolones in the Treatment of Community-Acquired Pneumonia in Neutropenic Patients