Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients (allogeneic SCT excluded): updated guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO).
Up to 25% of patients with profound neutropenia lasting for >10 days develop lung infiltrates, which frequently do not respond to broad-spectrum antibacterial therapy. While a causative pathogen remains undetected in the majority of cases, Aspergillus spp., Pneumocystis jirovecii, multi-resistant Gram-negative pathogens, mycobacteria or respiratory viruses may be involved. In at-risk patients who have received trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis, filamentous fungal pathogens appear to be predominant, yet commonly not proven at the time of treatment initiation. Pathogens isolated from blood cultures, bronchoalveolar lavage (BAL) or respiratory secretions are not always relevant for the etiology of pulmonary infiltrates and should therefore be interpreted critically. Laboratory tests for detecting Aspergillus galactomannan, β-D-glucan or DNA from blood, BAL or tissue samples may facilitate the diagnosis; however, most polymerase chain reaction assays are not yet standardized and validated. Apart from infectious agents, pulmonary side-effects from cytotoxic drugs, radiotherapy or pulmonary involvement by the underlying malignancy should be included into differential diagnosis and eventually be clarified by invasive diagnostic procedures. Pre-emptive treatment with mold-active systemic antifungal agents improves clinical outcome, while other microorganisms are preferably treated only when microbiologically documented. High-dose TMP/SMX is first choice for treatment of Pneumocystis pneumonia, while cytomegalovirus pneumonia is treated primarily with ganciclovir or foscarnet in most patients. In a considerable number of patients, clinical outcome may be favorable despite respiratory failure, so that intensive care should be unrestrictedly provided in patients whose prognosis is not desperate due to other reasons.
Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany. Electronic address: gmaschmeyer@klinikumevb.de.
G
G
Maschmeyer
Department of Infectious Diseases, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain.
J
J
Carratalà
Department of Hematology and Oncology, Mannheim University Hospital, Mannheim.
D
D
Buchheidt
Institution for Medical Microbiology, Immunology and Hygiene, University Hospital Cologne, Cologne.
A
A
Hamprecht
Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, University Hospital, Heidelberg.
C P
CP
Heussel
Department of Hematology and Oncology, Klinikum Magdeburg, Magdeburg.
C
C
Kahl
Department of Pneumology, Infectious Diseases, Sleep Medicine and Intensive Care, Klinikum Lüdenscheid, Lüdenscheid.
J
J
Lorenz
Medical Oncology, AMO MVZ, Wolfsburg.
S
S
Neumann
Department of Medicine III, University Hospital Großhadern, München.
C
C
Rieger
Department of Medical Oncology and Hematology, Charité University Medicine Campus Mitte, Berlin.
M
M
Ruhnke
Department of Hematology, Oncology, Stem Cell Transplantation, Asklepios Klinik Altona, Hamburg.
H
H
Salwender
Department of Hematology, Oncology and Tumor Immunology, Helios-Klinikum Berlin-Buch, Berlin, Germany.
M
M
Schmidt-Hieber
AP-HP, Hopital Saint-Louis, Service de Réanimation Médicale, Université Paris-Diderot, Sorbonne Paris-Cité, Faculté de Médecine, Paris, France.
E
E
Azoulay
D000890:Anti-Infective Agents / Q000627:therapeutic use*; D001992:Bronchoalveolar Lavage Fluid / Q000382:microbiology / Q000469:parasitology / Q000821:virology; D004338:Drug Combinations; D005334:Fever; D006801:Humans; D008168:Lung / Q000382:microbiology / Q000469:parasitology / Q000821:virology; D008171:Lung Diseases / Q000175:diagnosis* / Q000188:drug therapy* / Q000382:microbiology; D009503:Neutropenia; D013413:Sulfadoxine / Q000627:therapeutic use; D013492:Suppuration / Q000382:microbiology / Q000469:parasitology / Q000821:virology; D014295:Trimethoprim / Q000627:therapeutic use
D000890:Anti-Infective Agents; D004338:Drug Combinations; C000301:trimethoprim, sulfadoxine drug combination; D013413:Sulfadoxine; D014295:Trimethoprim
diagnosis; fever; lung infiltrates; neutropenia; pneumonia; treatment