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Neutropenia and Infections


Current Epidemiology and Prevention of Infectious Complications in Cancer Patients


Corrado Girmenia1 and Francesco Menichetti2


1. Assistant, Department of Haematology, Azienda Policlinico Umberto I, Rome; 2. Head, Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa


Abstract


Infections represent an important cause of morbidity and mortality in cancer patients, especially those patients receiving intensive chemotherapy or undergoing stem cell transplant. The changing epidemiological patterns of infections in cancer patients are characterised not only by the increasing incidence of some opportunistic pathogens, but also by the wide emergence of resistance to antimicrobials, particularly in bacteria. The management of these complications has improved greatly during the past decades, especially in the field of antimicrobial prophylaxis. In the last few years, new antimicrobial drugs have been investigated, with the aim of defining new strategies for prophylaxis against bacterial, fungal and viral infections. Based on the new evidence, international guidelines on antimicrobial prophylaxis have been recently updated, and targeted prophylaxis schedules have been proposed for different clinical settings. In the practice of antimicrobial prophylaxis, it is crucial to continuously keep abreast of new epidemiological data in order to monitor the emerging antimicrobial resistances and define tailored prevention strategies.


Keywords Infections, cancer, leukaemia, stem cell transplant, epidemiology, prophylaxis


Disclosure: Corrado Girmenia has received honoraria from Gilead Sciences, Schering-Plough, Astellas Pharma, Merck and Pfizer Pharmaceuticals. He has been a speaker for Gilead Sciences, Schering-Plough, Merck and Pfizer Pharmaceuticals. Francesco Menichetti has received honoraria from Gilead Sciences, Merck, Bayer, Novartis and Pfizer Pharmaceuticals. He has been a speaker for Gilead Sciences, Merck, Novartis and Pfizer Pharmaceuticals. Received: 26 September 2011 Accepted: 17 October 2011 Citation: European Oncology & Haematology, 2011;7(4):270–7 Correspondence: Corrado Girmenia, Dipartimento di Ematologia, Azienda Policlinico Umberto I, Via Benevento 6, 00161 Rome, Italy. E: girmenia@bce.uniroma1.it


Infections remain an important cause of morbidity and mortality in cancer patients, mainly those affected by haematological malignancies and those undergoing stem cell transplant (SCT).1–3 With the improvement of cancer care in the past decades, patients live longer, and immunosuppression from the underlying disease and from more intensive and prolonged treatments renders more and more of them susceptible to infections.


The epidemiological evolution of infectious complications in cancer patients is characterised not only by the increasing incidence of some opportunistic infections, such as invasive fungal diseases (IFDs), but also by the emergence of antimicrobial resistance in several bacteria and some fungi. Additionally, viruses are a serious and frequently underestimated cause of infection in cancer patients, particularly those subjected to SCT procedures, in whom careful surveillance and an antiviral prophylaxis strategy are required.


Thanks to the availability of new laboratory and imaging diagnostic tools and to the development of tailored surveillance strategies, a better knowledge of the epidemiology and risk/prognostic factors of infections has been gained in cancer centres in recent years. This epidemiological awareness is crucial to define prevention strategies adapted to the various categories of patients with different infection risks, and to chose treatment protocols likely to contain the


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above-mentioned phenomenon of resistance to antimicrobials. In this article, recent epidemiological findings on, and current prevention strategies against, bacterial, fungal and viral infections in cancer patients are reviewed and critically commented on.


Epidemiology of Infections in Cancer Patients Despite increasing attention to the clinical and therapeutic aspects of infection in cancer patients, few data are available on the incidence, microbiological characteristics and clinical outcomes of infectious complications in this population. Recent epidemiological data almost exclusively derive from retrospective studies and few prospective data are available. The susceptibility pattern to bacterial and fungal pathogens has been occasionally evaluated in the cancer population and most data derive from large microbiological studies in patients with various underlying conditions. Again, most data in the cancer setting derive from neutropenic patients affected by haematological malignancies and/or undergoing SCT.


Bacterial Infections


Over the past decades, the epidemiological spectrum of bloodstream bacterial isolates obtained from febrile neutropenic patients has continuously changed. During the 1960s and 1970s, gram-negative bacilli represented the predominant pathogens causing life-threatening infections. During the 1980s and 1990s, gram-positive organisms


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