Kanserli çocuklarda nötropenik ataklarda izlem ve tedavi
Management and treatment of febrile neutropenic episodes in children with cancer
Yazar: FUNDA ÇORAPÇIOĞLU
Danışman: PROF. DR. FAİK SARIALİOĞLU
Dokuz Eylül Üniversitesi / Tıp Fakültesi / Çocuk Sağlığı ve Hastalıkları Ana Bilim Dalı
Derece: Tıpta Yan Dal Uzmanlık, 2001
Konu: Onkoloji = Oncology ; Çocuk Sağlığı ve Hastalıkları = Child Health and Diseases

Özet:
Kanserli çocuklarda nötropenik ateş ataklarında temel tedavide ilkeleri belirlenmekle birlikte infeksiyon etkenlerinde zamanla ve merkez bağlı ortaya çıkan değişiklikler nedeniyle her merkez belirli periyodlarla kendi verilerini gözden geçirmelidir. Bu çalışmanın amacı son beş yılda merkezimizde izlenen nötropenik ateş ataklarını; infeksiyon etkenleri, tedavi şemalarının başarısı ve maliyetleri yönünden değerlendirerek gelecek yıllar için yerleşik bir tedavi protokolü oluşturulmasına katkıda bulunmaktır. HASTALAR VE YÖNTEM: 1 Ocak 1996-31 Mayıs 2001 tarihleri arasındaki sürede tanımlanan 96 nötropenik ateş atağı incelendi. Tüm ataklar; infeksiyon odakları ve etkenler, başlangıç ampirik tedavi şemaları, tedavi modifikasyonları, destek tedaviler, tedavi toksisitesi ve maliyeti yönünden değerlendirilerek, tedavi başarısı ve maliyeti üzerine etkili faktörlerin analizi yapıldı. BULGULAR: Belirtilen periyodda lenfoproliferatif ve solid tümörlü grupta izlenen eşit sayıdaki atakların o/",3>.-. %87'sinde absolü nötrofil sayısı 500/mm ün altında saptandı. Solid tümörlü hastalarda atak sıklığının giderek arttığı ve beklenen nötropeni süresinin uzun olduğu belirlendi. Atakların %34'ünde infeksiyon odağı bulunmazken, en sık rastlanan infeksiyon odakları oral mukoza ve gastrointestinal sistemdi. Atakların %15'inde etken mikrobiyolojik olarak tanımlandı ve %56 oranında etken Gram (-) bakterilerdi. Bakteriyemi tanımlanan beş ataktan üçünde etken Gram (+), ikisinde Gram (-) idi. En sık uygulanan ampirik tedavi ikili kombine antibiyotik şeması (%70) olup bu grupta 44 atakta seftazidim ve amikasin, 18 atakta karbapenem ve amikasin kombinasyonlarının kullanıldığı, atakların %6'sında monoterapi, %4'ünde glikopeptid, %18'inde anti-fungal ve %2'sinde anti-viral ilaç ilaveli şemaların başlandığı belirlendi. Ampirik tedavi başarısı %51 olup bu yanıt solid tümörlü grupta yüksekti. İlk 72 saatte hastaların %59'unda, ilk 5 günde %80'inde ateşin kontrol edildiği saptandı. Izlem döneminde hiçbir hasta kaybedilmedi. Lenfoproliferatif tümörlü ve nötropeni süresi uzun hastalarda ateşin kontrol süresinin uzun olduğu, hematopoetik büyüme faktörü uygulanımının tedavi yanıtına ek katkısı olmadığı saptandı. Hasta başına düşen toplam ortanca tedavi maliyeti 1506 USD bulundu. Lenfoproliferatif tümörlü, bakteriyemi saptanan, karbapenem ve amikasin ile anti-viral ajanların, büyüme faktörlerinin uygulandığı ataklarda tedavi maliyeti yüksek bulundu. YORUM: Merkezimizde izlenen kanserli çocuklarda gözlenen nötropenik ateş ataklarında ampirik tedavi başarı oranı %51 ve hasta kaybedilmemesi nedeniyle genel tedavi başarı oranı %100 olup seftazidim ve amikasin kombinasyonu etkinliği ve düşük maliyeti nedeniyle bugün için uygun bir kombinasyondur. Anahtar kelimeler: Nötropenik ateş, çocukluk çağı kanserleri, nötropeniSUMMARY MANAGEMENT AND TREATMENT OF FEBRILE NEUTROPENIC EPISODES IN CHILDREN WITH CANCER Funda Çorapçıoğlu, MD OBJECTIVES: Although main therapy principles of febrile neutropenic episodes in childhood cancers are determined, each institution has to overwiev its own data, periodically in aspects of changes upon infectious influences and institution depended factors. The objective of this study is to evaluate our data on febrile neutropenic episodes, infectious agents, success of treatment algorythms and treatment costs to form a more accurate treatment protocol for forthcoming years. PATIENTS AND METHODS: 96 febrile neutropenic episodes, diagnosed between January,18,,1996 and May,31sl, 2001, have been overwieved. Factors affecting treatment success and cost have been analysed by evaluating infection focuses, infectious agents, first step empirical treatment algorythms, modifications on treatment, supportive therapies, success and cost of treatment modalities used for all 96 febrile neutropenic episode cases. RESULTS: Within mentioned period, equal number of episodes were observed in both lymphoproliferative and solid tumor groups. In 87% of those cases, absolute neutrophil counts were below 500/mm3. In solid tumor group, episodes were more frequent and estimated neutropenic period was longer. In 34% of episodes, no infection focus was detected whereas most focuses were on mucosal surfaces and gastrointesinal system. Infectious agents were microbiologically identified in 15% of the cases and Gram negatives, which were responsible for 56% of the identified causes. Five cases had bacteremia, and three of them were Gram positives. Empirical therapy mostly were used, double combined therapy (70%), including, ceftazidime and amikacin in 44 episodes, carbapenem and amikacin in 18 episodes. In 6% of episodes, monotherapy was used. In 4%, glycopeptide, in 18% antifungal and in 2% antiviral drug was added to empirical treatment. Empirical treatment success was 51% and higher in the solid tumor group. Fever was controlled in 59% of the patients in first 72 hours, 80% of them in five days and none of the patients of died in the study group. In lymphoproliferative tumor and longer neutropenic period group, control of fever took more time. Applying haematopoietic growth factor added no benefit. Mean treatment cost for each patient was 1506 USD. Treatment costs were much more in patients, who had lymphoproliferative tumor, accompanied bacteremia, for which carbapenem and amikacin used and antiviral drugs added, growth factors used in therapy and modification on treatment was made. CONCLUSION: Empirical treatment success was 51% in our study group and overall treatment success was 100% because no death occured. The most appropriate treatment modality included ceftazidime and amikacin combination which has more effect and low cost. Key words: Neutropenic fever, childhood cancers, neutropenia.

Abstract:
Although main therapy principles of febrile neutropenic episodes in childhood cancers are determined, each institution has to overwiev its own data, periodically in aspects of changes upon infectious influences and institution depended factors. The objective of this study is to evaluate our data on febrile neutropenic episodes, infectious agents, success of treatment algorythms and treatment costs to form a more accurate treatment protocol for forthcoming years. PATIENTS AND METHODS: 96 febrile neutropenic episodes, diagnosed between January,18,,1996 and May,31sl, 2001, have been overwieved. Factors affecting treatment success and cost have been analysed by evaluating infection focuses, infectious agents, first step empirical treatment algorythms, modifications on treatment, supportive therapies, success and cost of treatment modalities used for all 96 febrile neutropenic episode cases. RESULTS: Within mentioned period, equal number of episodes were observed in both lymphoproliferative and solid tumor groups. In 87% of those cases, absolute neutrophil counts were below 500/mm3. In solid tumor group, episodes were more frequent and estimated neutropenic period was longer. In 34% of episodes, no infection focus was detected whereas most focuses were on mucosal surfaces and gastrointesinal system. Infectious agents were microbiologically identified in 15% of the cases and Gram negatives, which were responsible for 56% of the identified causes. Five cases had bacteremia, and three of them were Gram positives. Empirical therapy mostly were used, double combined therapy (70%), including, ceftazidime and amikacin in 44 episodes, carbapenem and amikacin in 18 episodes. In 6% of episodes, monotherapy was used. In 4%, glycopeptide, in 18% antifungal and in 2% antiviral drug was added to empirical treatment. Empirical treatment success was 51% and higher in the solid tumor group. Fever was controlled in 59% of the patients in first 72 hours, 80% of them in five days and none of the patients of died in the study group. In lymphoproliferative tumor and longer neutropenic period group, control of fever took more time. Applying haematopoietic growth factor added no benefit. Mean treatment cost for each patient was 1506 USD. Treatment costs were much more in patients, who had lymphoproliferative tumor, accompanied bacteremia, for which carbapenem and amikacin used and antiviral drugs added, growth factors used in therapy and modification on treatment was made. CONCLUSION: Empirical treatment success was 51% in our study group and overall treatment success was 100% because no death occured. The most appropriate treatment modality included ceftazidime and amikacin combination which has more effect and low cost. Key words: Neutropenic fever, childhood cancers, neutropenia.