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Gomez CB, Mitchell J, Marks BP. A decision analysis of cancer patients and the consumption of ready-to-eat salad. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2024. [PMID: 39389932 DOI: 10.1111/risa.17658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 07/25/2024] [Accepted: 08/14/2024] [Indexed: 10/12/2024]
Abstract
Listeria monocytogenes is a foodborne pathogen of concern for cancer patients, who face higher morbidity and mortality rates than the general population. The neutropenic diet (ND), which excludes fresh produce, is often utilized to mitigate this risk; however, an analysis weighing the theoretical listeriosis risk reduction of produce exclusion aspects of the ND and possible negative tradeoffs has never been conducted. Consequently, this work constructed decision analytic models using disability-adjusted life years (DALYs) to compare the impacts of the ND, such as increased neutropenic enterocolitis (NEC) likelihood, with three alternative dietary practices (safe food handling [SFH], surface blanching, and refrigeration only) across five age groups, for cancer patients who consume ready-to-eat salad. Less disruptive diets had fewer negative health impacts in all scenarios, with median alternative diet DALYs per person per chemotherapy cycle having lower values in terms of negative health outcomes (0.088-0.443) than the ND (0.619-3.102). DALYs were dominated by outcomes associated with NEC, which is more common in patients following the ND than in other diets. Switchover point analysis confirmed that, because of this discrepancy, there were no feasible values of other parameters that could justify the ND. Correspondingly, the sensitivity analysis indicated that NEC mortality rate and remaining life expectancy strongly affected DALYs, further illustrating the model's strong dependence on NEC outcomes. Given these findings, and the SFH's ease of implementation and high compliance rates, the SFH diet is recommended in place of the ND.
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Affiliation(s)
- Carly B Gomez
- Department of Biosystems and Agricultural Engineering, Michigan State University, East Lansing, Michigan, USA
| | - Jade Mitchell
- Department of Biosystems and Agricultural Engineering, Michigan State University, East Lansing, Michigan, USA
| | - Bradley P Marks
- Department of Biosystems and Agricultural Engineering, Michigan State University, East Lansing, Michigan, USA
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2
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Weber NT, Ogle S, Cooper EH, Kaizer AM, Kulungowski AM, Acker SN. Low-risk pneumatosis intestinalis in the pediatric surgical population. Pediatr Surg Int 2024; 40:76. [PMID: 38466447 DOI: 10.1007/s00383-024-05642-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Pneumatosis intestinalis (PI, presence of air in bowel wall) develops in a variety of settings and due to a variety of insults which is then characterized by varying severity and clinical course. Anecdotally, many of these cases are benign with few clinical sequelae; however, we lack evidence-based guidelines to help guide management of such lower-risk cases. We aimed to describe the clinical entity of low-risk PI, characterize the population of children who develop this form of PI, determine if management approach or clinical outcomes differed depending on the managing physician's field of practice, and finally determine if a shortened course of NPO and antibiotics was safe in the population of children with low-risk PI. METHODS We performed a retrospective review of all children over age 1 year treated at Children's Hospital Colorado (CHCO), between 2009 and 2019 with a diagnosis of PI who did not also have a diagnosis of cancer or history of bone marrow transplant (BMT). Data including demographic variables, clinical course, and outcomes were obtained from the electronic medical record. Low-risk criteria included no need for ICU admission, vasopressor use, or urgent surgical intervention. RESULTS Ninety-one children were treated for their first episode of PI during the study period, 72 of whom met our low-risk criteria. Among the low-risk group, rates of complications including hemodynamic decompensation during treatment, PI recurrence, Clostridium difficile colitis, and death did not differ between those who received 3 days or less of antibiotics and those who received more than 3 days of antibiotics. Outcomes also did not differ between children cared for by surgeons or pediatricians. CONCLUSIONS Here, we define low-risk PI as that which occurs in children over age 1 who do not have a prior diagnosis of cancer or prior BMT and who do not require ICU admission, vasopressor administration, or urgent surgical intervention. It is likely safe to treat these children with only 3 days of antibiotic therapy and NPO. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Nell T Weber
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave. Box 323, Aurora, CO, 80045, USA
- Center for Children's Surgery, Research Outcomes in Children's Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sarah Ogle
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave. Box 323, Aurora, CO, 80045, USA
| | - Emily H Cooper
- Center for Children's Surgery, Research Outcomes in Children's Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexander M Kaizer
- Center for Children's Surgery, Research Outcomes in Children's Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ann M Kulungowski
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave. Box 323, Aurora, CO, 80045, USA
- Center for Children's Surgery, Research Outcomes in Children's Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave. Box 323, Aurora, CO, 80045, USA.
- Center for Children's Surgery, Research Outcomes in Children's Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
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Benedetti E, Traverso G, Pucci G, Morganti R, Bramanti E, Lippolis P, Susini MC, Mazzantini E, Giubbolini R, Mavilia F, Capochiani E, Neri E, Arena C, Cerri F, De Simone L, Valentini K, Stella SM, Ricchiuto V, Bruno B, Galimberti S. Impact of different chemotherapy regimens on intestinal mucosal injury assessed with bedside ultrasound: a study in 213 AML patients. Front Oncol 2023; 13:1272072. [PMID: 38023169 PMCID: PMC10646482 DOI: 10.3389/fonc.2023.1272072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Neutropenic enterocolitis (NEC) is a life-threatening complication reported in patients with acute myeloid leukemia (AML) following chemotherapy (CHT). Intensive induction and consolidation CHT may damage intestinal mucosa leading to a NEC episode (NECe). NEC reported mortality may be up to 30-60%. Early US-guided bed-side diagnosis and prompt treatment may substantially improve the survival. An emerging worldwide concern is the intestinal colonization by multi-drug-resistant bacteria especially when patients are exposed to chemotherapy regimens potentially correlated to mucosal damage. Methods In our study we prospectively enrolled all AML patients admitted in our leukemia unit to receive intensive induction and consolidation chemotherapy and experiencing chemotherapy-induced-neutropenia (CHTN). Results and discussion Overall, we enrolled N=213 patients from 2007 to March 2023. We recorded N=465 CHTN, and N=42 NECe (9.0% incidence). The aim of our study was to assess which chemotherapy regimens are more associated with NEC. We found that ALM1310, followed by 7 + 3 (daunorubicin), 7 + 3 (idarubicin), 5 + 3 + 3 (cytarabine, etoposide, idarubicin), and AML1310 (consolidation) were associated with a statistically higher incidence of NEC. We did not detect NEC episodes in patients treated with CPX-351, 5 + 2 (cytarabine, idarubicine), and high-dose cytarabine. Thus, we found that cytarabine could determine mucosal damage when associated with an anthracycline but not if delivered either alone or as dual-drug liposomal encapsulation of daunorubicin/cytarabine. We also describe NEC mortality, symptoms at diagnosis, intestinal sites involvement, and prognostic significance of bowel wall thickening.
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Affiliation(s)
- Edoardo Benedetti
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Ginevra Traverso
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giulia Pucci
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Riccardo Morganti
- Section of Statistics, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Emilia Bramanti
- Institute of Chemistry of Organo Metallic Compounds (ICCOM), Consiglio Nazionale delle Ricerche (CNR), Pisa, Italy
| | - Piero Lippolis
- General and Peritoneal Surgery Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Maria Chiara Susini
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Elisa Mazzantini
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Fabrizio Mavilia
- Hematology Operative Unit (UO), Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Emanuele Neri
- Radiology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Chiara Arena
- Radiology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesca Cerri
- Radiology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Luigi De Simone
- Anesthesia and Maternal-Infantile Resuscitation Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Katia Valentini
- Anesthesia and Maternal-Infantile Resuscitation Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Vittorio Ricchiuto
- Dipartimento di Tecnologie Sanitarie ESTAR, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Benedetto Bruno
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Sara Galimberti
- Hematology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Acker SN, Ogle S, Cooper EH, Kaizer AM, Kulungowski AM. What is the role of neutropenia in pediatric cancer patients with pneumatosis intestinalis? Pediatr Surg Int 2023; 39:203. [PMID: 37219695 DOI: 10.1007/s00383-023-05485-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND We aimed to identify prognostic indicators in pneumatosis intestinalis (PI) in a pediatric oncology population. We hypothesized that neutropenia would be an independent risk factor for adverse outcomes, including the need for abdominal operation to treat PI and for the development of recurrent PI. METHODS We performed a retrospective review of all patients treated for PI between 2009 and 2019 with a diagnosis of cancer or history of bone marrow transplant (BMT). RESULTS Sixty-eight children were treated for their first episode of PI; 15 (22%) were not neutropenic at presentation; eight underwent urgent abdominal operation (12%). Patients with neutropenia were more likely to receive TPN, had a longer course of NPO, and received a longer course of antibiotics. Neutropenia at presentation was associated with a decreased risk of PI recurrence (40% vs 13%, p = 0.03). Children who required an abdominal operation were more likely to require vasopressors at diagnosis (50% vs 10%, p = 0.013). CONCLUSIONS Among pediatric cancer patients, need for vasopressors at the time of PI is a marker of severe PI, with increased likelihood of requiring operative intervention. The presence of neutropenia is associated with lower rates of PI recurrence. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Anschutz Medical Campus, Box 323, Aurora, CO, 80045, USA.
- The Surgical Oncology Program at Children's Hospital Colorado, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
- Research Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Sarah Ogle
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Anschutz Medical Campus, Box 323, Aurora, CO, 80045, USA
| | - Emily H Cooper
- Research Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexander M Kaizer
- Research Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ann M Kulungowski
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Anschutz Medical Campus, Box 323, Aurora, CO, 80045, USA
- The Surgical Oncology Program at Children's Hospital Colorado, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
- Research Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
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Intussception in Patients With Leukemia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023. [DOI: 10.1097/ipc.0000000000001204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Acker SN, Ogle S, Cooper E, Meier M, Peterson PN, Kulungowski AM. Current approaches to the management of pneumatosis intestinalis: an American Pediatric Surgical Association membership survey. Pediatr Surg Int 2022; 38:1965-1970. [PMID: 36242600 DOI: 10.1007/s00383-022-05249-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Pneumatosis intestinalis (PI) remains difficult to treat as it can lead to a broad range of clinical sequalae and there are little published data available to guide management. Our aim was to evaluate how pediatric surgeons currently manage children with PI, how treatment varies based on etiology, and to identify opportunities to optimize current PI management strategies. METHODS We administered a web-based survey of practicing pediatric surgeons in the United States and Canada. The survey was distributed to all members of the American Pediatric Surgical Association. RESULTS Of 1508 distributed surveys, 333 responses were received (22% response rate); 174 were complete and included in analysis (12% analyzed). For all scenarios, respondents recommended treatment for PI include a median 7 days of bowel rest and 7 days antibiotics. Only 41% reported their approach to PI management was optimal. Ways to optimize care include treatment based on etiology (83%), decreased number of repeat images (64%), shorter NPO course (49%), and shorter antibiotic course (47%). CONCLUSION Pediatric surgeons manage PI similarly regardless of etiology but most report this is suboptimal. Future work is needed to prospectively evaluate management protocols that consider etiology.
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Affiliation(s)
- Shannon N Acker
- Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Box 323, Aurora, CO, 80045, USA.
| | - Sarah Ogle
- Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Box 323, Aurora, CO, 80045, USA
| | - Emily Cooper
- Research Outcomes in Children's Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Maxene Meier
- Research Outcomes in Children's Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Pamela N Peterson
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Center, Aurora, CO, USA
- Division of Cardiology, Department of Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Ann M Kulungowski
- Division of Pediatric Surgery, Anschutz Medical Campus, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Box 323, Aurora, CO, 80045, USA
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Outcome and Determinants of Neutropenic Enterocolitis in Pediatric Cancer Patients. J Pediatr Hematol Oncol 2022; 44:376-382. [PMID: 35446793 DOI: 10.1097/mph.0000000000002422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neutropenic enterocolitis (NEC) is a dreaded complication of chemotherapy. There is scant literature regarding incidence, clinical features, and determinants. The understanding of gut dysbiosis in NEC and pediatric cancer is evolving. METHODS Pediatric cancer patients with neutropenia and gastrointestinal symptoms were evaluated for NEC with contrast-enhanced computed tomography abdomen. Clinical, imaging, and laboratory features were analyzed. Fecal samples were analyzed for fecal calprotectin by sandwich enzyme-linked immunoassay and gut microbiota by conventional culture and compared with healthy controls and children without NEC. RESULTS NEC was diagnosed in 44 children based on clinical and imaging features with incidence of 7.4% (4 had recurrent episodes). Common manifestations included fever (98%), pain abdomen (88%), and diarrhea (83%). Hypoalbuminemia was observed in 78% of patients. Large bowel involvement (94%) with diffuse bowel involvement (63%) and pancolitis (64%) were common. Fecal calprotectin was significantly elevated in NEC group than non-NEC group and healthy controls (median: 87, 53, and 42 µg/g, respectively). A higher degree of gut dysbiosis was observed in children with NEC with higher isolation of Bacteroides and infrequent isolation of Lactobacilli. Mortality rate of 23% was observed. Only the presence of free fluid predicted higher mortality. Though levels of fecal calprotectin and gut dysbiosis were higher in NEC, they did not increase mortality. Isolation of Bacteroides and absence of Lactobacilli predicted a longer duration of intravenous alimentation. CONCLUSIONS NEC caused significant morbidity and mortality in pediatric cancer patients. Gut dysbiosis was significantly higher in NEC group suggesting a role in pathogenesis and influencing outcome. This highlights the role of targeted interventions towards gut dysbiosis like prebiotics and probiotics.
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Imbert A, Sigal-Cinqualbre A, Genty T, Stéphan F. A Heart Transplant Patient With Fever, Diarrhea, and Neutropenia. Clin Infect Dis 2022; 75:1109-1110. [PMID: 36174247 DOI: 10.1093/cid/ciab894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Audrey Imbert
- Adult Intensive Care Unit, Hôpital Marie Lannelongue-Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Anne Sigal-Cinqualbre
- Radiology Department, Hôpital Marie Lannelongue-Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Thibaut Genty
- Adult Intensive Care Unit, Hôpital Marie Lannelongue-Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - François Stéphan
- Adult Intensive Care Unit, Hôpital Marie Lannelongue-Groupe Hospitalier Paris Saint Joseph, Paris, France.,Paris-Saclay University, School of Medicine, Paris, France
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Shiau J, Chin CC, Lou CW, Pan MR, Chen FM, Hou MF. Neutropenic necrotizing enterocolitis: A life-threatening complication after aggressive chemotherapy for leukemia. JOURNAL OF CANCER RESEARCH AND PRACTICE 2022. [DOI: 10.4103/jcrp.jcrp_19_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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White MG, Morgan RB, Drazer MW, Eng OS. Gastrointestinal Surgical Emergencies in the Neutropenic Immunocompromised Patient. J Gastrointest Surg 2021; 25:3258-3264. [PMID: 34506017 PMCID: PMC8665083 DOI: 10.1007/s11605-021-05116-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/03/2021] [Indexed: 01/31/2023]
Abstract
Surgeons encounter neutropenic patients through elective or emergency consultation with increasing regularity. As medical management continues to extend the lives of patients with benign hematologic diseases, hematologic malignancies, solid malignancies, or iatrogenic neutropenia, more patients are presenting with infectious complications caused and/or complicated by their neutropenia. This leaves surgeons in the difficult position of managing medically fragile patients with unusual presentations of common disease processes. These patients often fall outside of classical guidelines and treatment pathways. Many studies addressing these issues are retrospective and non-randomized. Here, we review common emergency gastrointestinal surgery scenarios and their management in the setting of a neutropenic patient. While biliary disease, appendicitis, anorectal disease, and perforations will be covered in detail, an extensive appreciation of a patient's medical or oncologic disease course and appropriate utilization of consultants such as interventional radiology, gastroenterology, and hematology is often necessary.
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Affiliation(s)
- Michael G White
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ryan B Morgan
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago, 5841 S. Maryland Ave, G 205, MC 5094, Chicago, IL, 60637, USA
| | - Michael W Drazer
- Department of Medicine and Human Genetics, Section of Hematology and Oncology, University of Chicago, 5841 S. Maryland Ave, G 205, MC 5094, Chicago, IL, 60637, USA
| | - Oliver S Eng
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago, 5841 S. Maryland Ave, G 205, MC 5094, Chicago, IL, 60637, USA.
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Early Diagnosis of Neutropenic Enterocolitis by Bedside Ultrasound in Hematological Malignancies: A Prospective Study. J Clin Med 2021; 10:jcm10184277. [PMID: 34575387 PMCID: PMC8468879 DOI: 10.3390/jcm10184277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 08/23/2021] [Accepted: 09/13/2021] [Indexed: 02/06/2023] Open
Abstract
(1) Background: Neutropenic enterocolitis (NEC) is a life-threatening complication following chemotherapy with high mortality rates. Early diagnosis is crucial to improve outcomes. We designed a large prospective study employing bedside ultrasonography (US) as a novel approach to allow early diagnosis and prompt treatment to reduce mortality. (2) Methods: NEC was defined as US or computed tomography (CT)-proven bowel wall thickness ≥ 4 mm at the onset of at least one of the following symptoms: fever and/or abdominal pain and/or diarrhea during neutropenia. From 2007 to 2018, 1754 consecutive patients underwent baseline bedside US that was invariably repeated within 12 h from the onset of symptom(s) suggestive of NEC. (3) Results: Overall, 117 episodes of NEC were observed, and overall mortality was 9.4%. Bowel wall thickening was invariably absent in the negative control group. Abdominal pain associated with one or more symptoms correlated with the highest relative risk (17.33), sensitivity (89.7%), specificity (100%), and accuracy (96.2%) for diagnosis. The combination of abdominal pain and fever at onset significantly correlated with worse survival (p < 0.0001, OR 13.85). BWT (p = 0.046), type of therapy (p = 0.049) and blood culture positivity (p = 0.003) correlated with worse survival. (4) Conclusions: Bedside ultrasound is a non-invasive and radiation free imaging technique for early diagnosis of NEC and its prompt treatment significantly reduced mortality.
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Fenton R, Schneiders H, Reid J. Good functional outcome following severe neutropenic enterocolitis and perforation in a 48-year-old woman undergoing chemotherapy for breast cancer. BMJ Case Rep 2021; 14:14/3/e238277. [PMID: 33653834 PMCID: PMC7929857 DOI: 10.1136/bcr-2020-238277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Neutropenic enterocolitis (NEC) is a life-threatening bowel condition, usually resulting from chemotherapy, with a mortality rate thought to be as high as 50%. Markers of poor prognosis include gastrointestinal perforation and bowel wall thickness radiologically detected to be greater than 10 mm. NEC is associated with severe neutropenia and predominantly affects the large bowel; however, we present a case of severe NEC with oesophageal perforation requiring transfer to a specialist upper gastrointestinal unit for corrective stenting. Despite initial bowel wall thickness of 20 mm in the ascending colon, two discrete episodes of bowel perforation and an inpatient stay totalling 89 days, the patient was discharged with full independence, a good quality of life and a plan for curative mastectomy plus axillary clearance.
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Affiliation(s)
| | | | - Jeremy Reid
- Anaesthesia, Yeovil District Hospital, Yeovil, UK
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Abstract
BACKGROUND Patients undergoing chemotherapy are at risk for mucosal injury and neutropenia, which facilitate colonic mucosal invasion by the bowel flora and subsequent neutropenic enterocolitis, which has a poor prognosis. OBJECTIVE This study aimed to assess the clinical features and outcomes of neutropenic enterocolitis in patients at a comprehensive cancer center. DESIGN This is a retrospective cohort study. SETTING The study was conducted at the University of Texas MD Anderson Cancer Center. PATIENTS Neutropenic enterocolitis was defined by the presence of an absolute neutrophil count <1000/mm, compatible abdominal symptoms, and either mucosal thickening on abdominal imaging or mucosal injury on colon biopsy. Patients who had been diagnosed between 2010 and 2018 were included. MAIN OUTCOMES Complication and survival rates were analyzed using logistic regression and Cox regression analyses, respectively. RESULTS Of the 49,244 patients who had neutropenia during the study period, 134 (2.7%) were included. The median time from neutropenia onset to neutropenic enterocolitis was 2 days (interquartile range, 1-10 days). Neutropenic enterocolitis symptoms lasted for a median of 11 days (interquartile range, 6-22 days). Most patients received antibiotics (88%) and granulocyte colony-stimulating factor (68%). Complications included sepsis (11%), colonic perforation (2%), pneumatosis intestinalis (2%), and abscess formation (2%). The risks associated with complications included immunosuppressive therapy use within 1 month before neutropenic enterocolitis onset (OR, 3.92; 95% CI, 1.04-14.76) and delayed imaging (OR, 1.10; 95% CI, 1.03-1.17). Older age, severe neutropenia, prolonged neutropenia before and after neutropenic enterocolitis diagnosis, and other concomitant systemic infections were associated with lower survival rates. LIMITATIONS The performance of this study at a single center and its retrospective nature are limitations of the study. CONCLUSION The prompt diagnosis and management of neutropenic enterocolitis are critical to prevent complications. The use of granulocyte colony-stimulating factor can be beneficial to shorten the duration of neutropenia. See Video Abstract at http://links.lww.com/DCR/B116. ENTEROCOLITIS NEUTROPÉNICA: CARACTERÍSTICAS CLÍNICAS Y RESULTADOS: Los pacientes sometidos a quimioterapia, están en riesgo de lesión de la mucosa y neutropenia, lo que facilita la invasión de la mucosa colónica por la flora intestinal y la subsecuente enterocolitis neutropénica, con un mal pronóstico.Evaluar las características clínicas y los resultados de la enterocolitis neutropénica de pacientes en un centro integral de cáncer.Estudio de cohorte retrospectivo.El estudio se realizó en el MD Anderson Cancer Center de la Universidad de Texas.Se definió la enterocolitis neutropénica, como la presencia de un recuento absoluto de neutrófilos <1000 / mm3, con síntomas compatibles abdominales y engrosamiento de la mucosa en imagen abdominal o lesión de la mucosa en biopsia de colon. Se incluyeron pacientes diagnosticados entre 2010 y 2018.Se analizaron las tasas de complicaciones y supervivencia mediante análisis de regresión logística y regresión de Cox.De 49,244 pacientes que tuvieron neutropenia durante el período de estudio, 134 (2.7%) fueron incluidos. La media del tiempo desde el inicio de la neutropenia hasta la enterocolitis neutropénica, fue de 2 días (RIC, 1-10 días). Los síntomas de enterocolitis neutropénica duraron una media de 11 días (RIC, 6-22 días). La mayoría de los pacientes recibieron antibióticos (88%) y factor estimulante de colonias de granulocitos (68%). Las complicaciones incluyeron sepsis (11%), perforación colónica (2%), neumatosis intestinal (2%) y formación de abscesos (2%). Los riesgos asociados con las complicaciones incluyeron, uso de terapia inmunosupresora dentro de 1 mes antes del inicio de la enterocolitis neutropénica (razón de probabilidades 3.92; intervalo de confianza del 95% 1.04-14.76) y demora en la obtención de imágenes (razón de probabilidades 1.10; intervalo de confianza del 95% 1.03-1.17), edad avanzada, neutropenia grave, neutropenia prolongada antes y después del diagnóstico de enterocolitis neutropénica y de otras infecciones sistémicas concomitantes, se asociaron con bajas tasas de supervivencia.Centro único y estudio retrospectivo.El rápidodiagnóstico y manejo de la enterocolitis neutropénica, es crítico para prevenir complicaciones. El uso del factor estimulante de colonias de granulocitos puede ser beneficioso para acortar la duración de la neutropenia. Consulte Video Resumen en http://links.lww.com/DCR/B116.
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Kaito S, Sekiya N, Najima Y, Sano N, Horiguchi S, Kakihana K, Hishima T, Ohashi K. Fatal Neutropenic Enterocolitis Caused by Stenotrophomonas maltophilia: A Rare and Underrecognized Entity. Intern Med 2018; 57:3667-3671. [PMID: 30101922 PMCID: PMC6355424 DOI: 10.2169/internalmedicine.1227-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Although Stenotrophomonas maltophilia causes substantial morbidity and mortality in immunocompromised patients, it has not been described as a causal pathogen of neutropenic enterocolitis (NEC). We describe the first case of histologically-confirmed NEC caused by S. maltophilia accompanied by bacteremia and pneumonia after salvage chemotherapy for acute myeloid leukemia relapse following a second hematopoietic stem cell transplantation. S. maltophilia should be included as a pathogenic organism of NEC in severely immunocompromised patients to prevent a delayed diagnosis, which carries a high risk of inappropriate antimicrobial selection and fatal outcome.
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Affiliation(s)
- Satoshi Kaito
- Division of Hematology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
- Department of Clinical Laboratory, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Noritaka Sekiya
- Department of Clinical Laboratory, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
- Department of Infection Prevention and Control, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Yuho Najima
- Division of Hematology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Naoki Sano
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Shinichiro Horiguchi
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Kazuhiko Kakihana
- Division of Hematology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Tsunekazu Hishima
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Kazuteru Ohashi
- Division of Hematology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
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15
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Saillard C, Zafrani L, Darmon M, Bisbal M, Chow-Chine L, Sannini A, Brun JP, Ewald J, Turrini O, Faucher M, Azoulay E, Mokart D. The prognostic impact of abdominal surgery in cancer patients with neutropenic enterocolitis: a systematic review and meta-analysis, on behalf the Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie (GRRR-OH). Ann Intensive Care 2018; 8:47. [PMID: 29675758 PMCID: PMC5908777 DOI: 10.1186/s13613-018-0394-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/12/2018] [Indexed: 12/15/2022] Open
Abstract
Neutropenic enterocolitis (NE) is a diagnostic and therapeutic challenge associated with high mortality rates, with controversial opinions on its optimal management. Physicians are usually reluctant to select surgery as the first-choice treatment, concerns being raised regarding the potential risks associated with abdominal surgery during neutropenia. Nevertheless, no published studies comforted this idea, literature is scarce and surgery has never been compared to medical treatment. This review and meta-analysis aimed to determine the prognostic impact of abdominal surgery on outcome of neutropenic cancer patients presenting with NE, versus medical conservative treatment. This meta-analysis included studies analyzing cancer patients presenting with NE, treated with surgical or medical treatment, searched by PubMed and Cochrane databases (1983–2016), according to PRISMA recommendations. The endpoint was hospital mortality. Fixed-effects models were used. The meta-analysis included 20 studies (385 patients). Overall estimated mortality was 42.2% (95% CI = 40.2–44.2). Abdominal surgery was associated with a favorable outcome with an OR of 0.41 (95% CI = 0.23–0.74; p = 0.003). Pre-defined subgroups analysis showed that neither period of admission, underlying malignancy nor neutropenia during the surgical procedure, influenced this result. Surgery was not associated with an excess risk of mortality compared to medical treatment. Defining the optimal indications of surgical treatment is needed. Trial registration PROSPERO CRD42016048952
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Affiliation(s)
- Colombe Saillard
- Haematology Department, Institut Paoli Calmettes, 232 Boulevard Sainte Marguerite, 13009, Marseille Cedex 09, France.
| | - Lara Zafrani
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Michael Darmon
- Medical-Surgical Intensive Care Unit, Hôpital Nord, Université Jean Monnet, Saint Etienne, France.,GRRR-OH (Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie), Paris, France
| | - Magali Bisbal
- GRRR-OH (Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie), Paris, France.,Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Laurent Chow-Chine
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Antoine Sannini
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Jean-Paul Brun
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Jacques Ewald
- Surgery Department, Institut Paoli Calmettes, Marseille, France
| | - Olivier Turrini
- Surgery Department, Institut Paoli Calmettes, Marseille, France
| | - Marion Faucher
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France.,GRRR-OH (Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie), Paris, France.,Faculté de Médecine, Université Paris Diderot, Sorbonne-Paris-Cité, Paris, France
| | - Djamel Mokart
- GRRR-OH (Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie), Paris, France.,Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
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16
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Schmidt-Hieber M, Bierwirth J, Buchheidt D, Cornely OA, Hentrich M, Maschmeyer G, Schalk E, Vehreschild JJ, Vehreschild MJGT. Diagnosis and management of gastrointestinal complications in adult cancer patients: 2017 updated evidence-based guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol 2018; 97:31-49. [PMID: 29177551 PMCID: PMC5748412 DOI: 10.1007/s00277-017-3183-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/11/2017] [Indexed: 12/15/2022]
Abstract
Cancer patients frequently suffer from gastrointestinal complications. In this manuscript, we update our 2013 guideline on the diagnosis and management of gastrointestinal complications in adult cancer patients by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). An expert group was put together by the AGIHO to update the existing guideline. For each sub-topic, a literature search was performed in PubMed, Medline, and Cochrane databases, and strengths of recommendation and the quality of the published evidence for major therapeutic strategies were categorized using the 2015 European Society for Clinical Microbiology and Infectious Diseases (ESCMID) criteria. Final recommendations were approved by the AGIHO plenary conference. Recommendations were made with respect to non-infectious and infectious gastrointestinal complications. Strengths of recommendation and levels of evidence are presented. A multidisciplinary approach to the diagnosis and management of gastrointestinal complications in cancer patients is mandatory. Evidence-based recommendations are provided in this updated guideline.
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Affiliation(s)
- M Schmidt-Hieber
- Clinic for Hematology, Oncology, Tumor Immunology and Palliative Care, HELIOS Klinikum Berlin-Buch, Berlin, Germany
| | - J Bierwirth
- Deutsches Beratungszentrum für Hygiene, BZH GmbH, Freiburg, Germany
| | - D Buchheidt
- 3rd Department of Internal Medicine - Hematology and Oncology - Mannheim University Hospital, University of Heidelberg, Heidelberg, Germany
| | - O A Cornely
- 1st Department of Internal Medicine, University of Cologne, Cologne, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
- Clinical Trials Centre Cologne, ZKS Köln, University of Cologne, Cologne, Germany
| | - M Hentrich
- Department III for Internal Medicine, Hematology and Oncology, Rotkreuzklinikum München, Munich, Germany
| | - G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Ernst-von-Bergmann Klinikum, Potsdam, Germany
| | - E Schalk
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University, Magdeburg, Germany
| | - J J Vehreschild
- 1st Department of Internal Medicine, University of Cologne, Cologne, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
| | - Maria J G T Vehreschild
- 1st Department of Internal Medicine, University of Cologne, Cologne, Germany.
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany.
- 1st Department of Internal Medicine, Hospital of the University of Cologne, Kerpener Str. 62, 50937, Köln, Germany.
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17
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A fresh look at polymicrobial bloodstream infection in cancer patients. PLoS One 2017; 12:e0185768. [PMID: 29065118 PMCID: PMC5655483 DOI: 10.1371/journal.pone.0185768] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 09/19/2017] [Indexed: 12/12/2022] Open
Abstract
Objectives To assess the current incidence, clinical features, risk factors, aetiology, antimicrobial resistance and outcomes of polymicrobial bloodstream infection (PBSI) in patients with cancer. Methods All prospectively collected episodes of PBSI in hospitalised patients were compared with episodes of monomicrobial bloodstream infection (MBSI) between 2006 and 2015. Results We identified 194 (10.2%) episodes of PBSI and 1702 MBSI (89.8%). The presence of cholangitis, biliary stenting, neutropenia, corticosteroids, neutropenic enterocolitis and other abdominal infections were identified as risk factors for PBSI. Overall, Gram-negative organisms were the most frequent aetiology, but Enterococcus spp. were especially frequent causes of Gram-positive PBSI (30.8%). Multidrug-resistant (MDR) organisms were more commonly found in PBSI than in MBSI (20.6% vs 12.9%; p = 0.003). Compared to patients with MBSI, those with PBSI presented with higher early (15% vs 1.4%; p = 0.04) and overall (32% vs 20.9%; p<0.001) case-fatality rates. Risk factors for overall case-fatality were a high-risk MASCC (Multinational Association of Supportive Care in Cancer) index score, corticosteroid use, persistent bacteraemia and septic shock. Conclusions PBSI is a frequent complication in patients with cancer and is responsible for high mortality rates. Physicians should identify patients at risk for PBSI and provide empiric antibiotic therapy that covers the most frequent pathogens involved in these infections, including MDR strains.
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19
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Prise en charge du patient neutropénique en réanimation (nouveau-nés exclus). Recommandations d’un panel d’experts de la Société de réanimation de langue française (SRLF) avec le Groupe francophone de réanimation et urgences pédiatriques (GFRUP), la Société française d’anesthésie et de réanimation (Sfar), la Société française d’hématologie (SFH), la Société française d’hygiène hospitalière (SF2H) et la Société de pathologies infectieuses de langue française (SPILF). MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1278-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Rodrigues FG, Dasilva G, Wexner SD. Neutropenic enterocolitis. World J Gastroenterol 2017; 23:42-47. [PMID: 28104979 PMCID: PMC5221285 DOI: 10.3748/wjg.v23.i1.42] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/18/2016] [Accepted: 12/08/2016] [Indexed: 02/06/2023] Open
Abstract
Neutropenic colitis is a severe condition usually affecting immunocompromised patients. Its exact pathogenesis is not completely understood. The main elements in disease onset appear to be intestinal mucosal injury together with neutropenia and the weakened immune system of the afflicted patients. These initial conditions lead to intestinal edema, engorged vessels, and a disrupted mucosal surface, which becomes more vulnerable to bacterial intramural invasion. Chemotherapeutic agents can cause direct mucosal injury (mucositis) or can predispose to distension and necrosis, thereby altering intestinal motility. This article aims to review current concepts regarding neutropenic colitis’ pathogenesis, diagnosis, and management.
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21
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Marchetti O, Tissot F, Calandra T. Infections in the Cancer Patient. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00079-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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22
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Chow EJ, Bishop KD. Painless neutropenic enterocolitis in a patient undergoing chemotherapy. ACTA ACUST UNITED AC 2016; 23:e514-e516. [PMID: 27803612 DOI: 10.3747/co.23.3119] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CASE DESCRIPTION A 60-year-old man developed painless neutropenic enterocolitis after induction chemotherapy for newly diagnosed acute myelogenous leukemia. The patient had recurrent fever while neutropenic, without experiencing abdominal pain or tenderness on physical examination. His diagnosis was delayed by the fact that he had no localizing symptoms. DISCUSSION Neutropenic enterocolitis is a common complication, generally occurring in patients who are severely neutropenic; the condition presents with fever and abdominal pain. No cases of painless neutropenic enterocolitis have yet been reported. Review of the literature shows that patients can develop this condition in the absence of fever and, sometimes, neutropenia. Furthermore, few comprehensive studies or reviews have investigated the utility of computed tomography imaging in identifying a source for abdominal pain in neutropenic patients with fever. SUMMARY Many potential causes of febrile neutropenia should be considered in chemotherapy patients.
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Affiliation(s)
- E J Chow
- Departments of Medicine and Pediatrics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, and Hasbro Children's Hospital, Providence, RI, U.S.A
| | - K D Bishop
- Department of Medicine, Division of Hematology and Oncology, Warren Alpert Medical School of Brown University, Providence, RI, U.S.A
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23
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Schnell D, Azoulay E, Benoit D, Clouzeau B, Demaret P, Ducassou S, Frange P, Lafaurie M, Legrand M, Meert AP, Mokart D, Naudin J, Pene F, Rabbat A, Raffoux E, Ribaud P, Richard JC, Vincent F, Zahar JR, Darmon M. Management of neutropenic patients in the intensive care unit (NEWBORNS EXCLUDED) recommendations from an expert panel from the French Intensive Care Society (SRLF) with the French Group for Pediatric Intensive Care Emergencies (GFRUP), the French Society of Anesthesia and Intensive Care (SFAR), the French Society of Hematology (SFH), the French Society for Hospital Hygiene (SF2H), and the French Infectious Diseases Society (SPILF). Ann Intensive Care 2016; 6:90. [PMID: 27638133 PMCID: PMC5025409 DOI: 10.1186/s13613-016-0189-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 08/29/2016] [Indexed: 02/07/2023] Open
Abstract
Neutropenia is defined by either an absolute or functional defect (acute myeloid leukemia or myelodysplastic syndrome) of polymorphonuclear neutrophils and is associated with high risk of specific complications that may require intensive care unit (ICU) admission. Specificities in the management of critically ill neutropenic patients prompted the establishment of guidelines dedicated to intensivists. These recommendations were drawn up by a panel of experts brought together by the French Intensive Care Society in collaboration with the French Group for Pediatric Intensive Care Emergencies, the French Society of Anesthesia and Intensive Care, the French Society of Hematology, the French Society for Hospital Hygiene, and the French Infectious Diseases Society. Literature review and formulation of recommendations were performed using the Grading of Recommendations Assessment, Development and Evaluation system. Each recommendation was then evaluated and rated by each expert using a methodology derived from the RAND/UCLA Appropriateness Method. Six fields are covered by the provided recommendations: (1) ICU admission and prognosis, (2) protective isolation and prophylaxis, (3) management of acute respiratory failure, (4) organ failure and organ support, (5) antibiotic management and source control, and (6) hematological management. Most of the provided recommendations are obtained from low levels of evidence, however, suggesting a need for additional studies. Seven recommendations were, however, associated with high level of evidences and are related to protective isolation, diagnostic workup of acute respiratory failure, medical management, and timing surgery in patients with typhlitis.
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Affiliation(s)
| | | | | | - Benjamin Clouzeau
- Medical Intensive Care Unit, Pellegrin University Hospital, Bordeaux, France
| | - Pierre Demaret
- Paediatric Intensive Care Unit, Centre Hospitalier Chrétien, Liège, Belgium
| | - Stéphane Ducassou
- Pediatric Hematological Unit, Bordeaux University Hospital, Bordeaux, France
| | - Pierre Frange
- Microbiology Laboratory & Pediatric Immunology - Hematology Unit, Necker University Hospital, Paris, France
| | - Matthieu Lafaurie
- Department of Infectious Diseases, Saint-Louis University Hospital, Paris, France
| | - Matthieu Legrand
- Surgical ICU and Burn Unit, Saint-Louis University Hospital, Paris, France
| | - Anne-Pascale Meert
- Thoracic Oncology Department and Oncologic Intensive Care Unit, Institut Jules Bordet, Brussels, Belgium
| | - Djamel Mokart
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmette, Marseille, France
| | - Jérôme Naudin
- Pediatric ICU, Robert Debré University Hospital, Paris, France
| | | | - Antoine Rabbat
- Respiratory Intensive Care Unit, Cochin University Hospital Hospital, Paris, France
| | - Emmanuel Raffoux
- Department of Hematology, Saint-Louis University Hospital, Paris, France
| | - Patricia Ribaud
- Department of Stem Cell Transplantation, Saint-Louis University Hospital, Paris, France
| | | | | | - Jean-Ralph Zahar
- Infection Control Unit, Angers University Hospital, Angers, France
| | - Michael Darmon
- University Hospital, Saint-Etienne, France. .,Medical-Surgical Intensive Care Unit, Saint-Etienne University Hospital, Avenue Albert Raymond, 42270, Saint-Etienne, Saint-Priest-En-Jarez, France.
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Abstract
Neutropenic enterocolitis (NE) is a deadly ileocecal-based disease seen in patients with a recent history of chemotherapy. As histology is not included in the current diagnostic criteria, the pathologic features of NE are poorly understood. We undertook a multi-institutional study of NE, and report helpful clinical clues, such as immunosuppression (n=20/20), recent chemotherapy (n=17/18), neutropenia (n=16/18) gastrointestinal symptoms (n=19/19), abnormal imaging studies of the cecum/right colon (n=11/14), and positive microbiological studies (n=13/15). Fever (n=9/15) and sepsis (n=8/16) were also common. Pathologically, the cecum/right colon was always involved (n=17/17), but findings were identified in other bowel segments as well. NE lesions consisted of patchy necrosis (n=18/20), infiltrating organisms (n=17/20), hemorrhage (n=15/20), ulcer (n=15/19), edema (n=15/20), and depletion of inflammatory cells (n=15/20). Seventy-nine percent (n=15/19) of patients with histologically confirmed NE died: 47% (n=7/15) of these deaths were attributed to NE and the remainder to the patients' underlying conditions. Importantly, we observed a clinical diagnostic discordancy rate of 35% (n=9/26): 15% (n=3/20) of histologically confirmed NE were clinically unsuspected, and 26% (n=6/23) of clinically suspected NE represented a different disease process. Alternative diagnoses included unspecified colitis, infection, graft-versus-host disease, relapsed malignancy, mycophenolate injury, appendicitis, and ischemia. The causes of death in patients with NE mimics included unrecognized appendicitis and unrecognized graft-versus-host disease. To improve diagnostic accuracy, we propose that histology be required for a diagnosis of "definitive NE," with other clinically suspicious cases reported as "suspicious for NE" until all other possible diagnoses have been reasonably excluded.
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Sullivan PS, Moreno C, Shaib WL. Management of anorectal and intra-abdominal infections in the neutropenic cancer patient. Curr Probl Cancer 2015; 39:274-86. [PMID: 26566580 DOI: 10.1016/j.currproblcancer.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
The anatomic pathologist's ability to diagnose infections, including gastrointestinal infections, in tissue sections has improved greatly in recent years. With the increasing number and availability of new molecular assays and immunostains, pathologists' understanding of the correlation between histologic patterns of inflammation and specific organisms or groups of organisms has expanded, as well as our understanding of how closely infections can mimic other frequently encountered diseases in gastrointestinal pathology (such as chronic idiopathic inflammatory bowel disease and ischemia). Anatomic pathologists continue to play a critical role in the diagnosis of gastrointestinal infections, as the examination of slides may provide a much more rapid result than microbiological cultures or other laboratory assays, and often cultures are not obtained before the patient is treated with antibiotics. Because many gastrointestinal infections are acquired through contaminated water and food, this review will focus primarily on food and water-borne infectious enterocolitides.
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Affiliation(s)
- Laura W Lamps
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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28
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Bayasi M, Quiogue J. Noninfectious colitides. Clin Colon Rectal Surg 2015; 28:87-92. [PMID: 26034404 DOI: 10.1055/s-0035-1549847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
There are numerous etiologic and pathogenic mechanisms associated with colitis, ranging from infectious to noninfectious colitis. However, despite their different causes, their presentations are often similar making it difficult to formulate the correct diagnosis. This article describes the presentation, endoscopic and pathological findings of six different noninfectious colitides: diversion colitis, neutropenic enterocolitis, disinfectant colitis, corrosive colitis, nonsteroidal anti-inflammatory drug and salicylate-induced colitis, and toxic epidermal necrolysis. In addition, this article discusses the management and current treatment options for these six colitides.
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Affiliation(s)
- Mohammed Bayasi
- Colorectal Surgery Program, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Jose Quiogue
- Section of Colon and Rectal Surgery, MedStar Washington Hospital Center, Washington, District of Columbia
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Barral M, Boudiaf M, Dohan A, Hoeffel C, Camus M, Pautrat K, Fishman E, Cohen S, Soyer P. MDCT of acute colitis in adults: An update in current imaging features. Diagn Interv Imaging 2015; 96:133-49. [DOI: 10.1016/j.diii.2014.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Healthy individuals possess an immune system comprising physical barriers, innate and acquired immunity as well as the indigenous microflora that populate the body surfaces. The immune system maintains constant vigilance over the body at the cellular level as well as at the interface between the host integument and the resident microflora. However, neoplastic diseases and their treatment often lead to impaired immunity resulting in an increased risk of infections due to viruses, bacteria, fungi, and protozoa. This chapter explores the various aspects of host impairment focusing on the components of immunity and the interplay between them to explain why it is that these patients succumb to infections per se. In so doing, we hope that the reader will be better equipped to understand the risks patients face so as to anticipate potential infectious complications and implement appropriate measures to help attain successful remission of the neoplastic diseases and maintain the best quality of life for the patient.
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Affiliation(s)
- Valentina Stosor
- Div. Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois USA
| | - Teresa R. Zembower
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois USA
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Abstract
Cancer patients, particularly those with neutropenia, are at risk for enteric and intra-abdominal infections. Specific infections and infectious syndromes in this setting include neutropenic enterocolitis, bacterial infections such as Clostridium difficile infection (CDI), viral infections such as CMV colitis, and parasitic infections such as strongyloidiasis. Diagnosing and gauging the severity of CDI presents challenges, as chemotherapy may produce symptoms that mimic CDI and laboratory findings such as leukocytosis are not reliable in this population. Treatment for enteric infections should be pathogen specific, although broad-spectrum antibiotics are often required as initial empiric therapy in patients with neutropenia.
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Affiliation(s)
- Michael Wang
- Division of Infectious Diseases, Lakeland Regional Medical Center, 1234 Napier Avenue, St. Joseph, MI, 49085, USA,
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Nesher L, Rolston KVI. Neutropenic enterocolitis, a growing concern in the era of widespread use of aggressive chemotherapy. Clin Infect Dis 2012. [PMID: 23196957 DOI: 10.1093/cid/cis998] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Neutropenic enterocolitis (NEC) is a life-threatening disease with substantial morbidity and mortality, seen primarily in patients with hematologic malignancies. The frequency of NEC has increased with the widespread use of chemotherapeutic agents such as the taxanes, which cause severe gastrointestinal mucositis. Neutropenic patients with fever and abdominal symptoms (cramping, pain, distention, diarrhea, GI bleeding), should undergo evaluation of the abdomen for bowel wall thickening of >4 mm, the hallmark of NEC. Clostridium difficile infection should be ruled out, as well as other etiologies such as graft-versus-host disease. Complications include bacteremia, which is often polymicrobial, hemorrhage, and bowel wall perforation/abscess formation. Management includes bowel rest, correction of cytopathies and coagulopathies, and broad spectrum antibiotics and antifungal agents. Surgical intervention may be necessary to manage complications such as hemorrhage and perforation and should be delayed, if possible, until recovery from neutropenia.
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Affiliation(s)
- Lior Nesher
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Gil L, Poplawski D, Mol A, Nowicki A, Schneider A, Komarnicki M. Neutropenic enterocolitis after high-dose chemotherapy and autologous stem cell transplantation: incidence, risk factors, and outcome. Transpl Infect Dis 2012; 15:1-7. [DOI: 10.1111/j.1399-3062.2012.00777.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 03/26/2012] [Accepted: 04/03/2012] [Indexed: 11/28/2022]
Affiliation(s)
- L. Gil
- Department of Hematology; Poznan University of Medical Sciences; Poznan; Poland
| | - D. Poplawski
- Department of Radiology; Poznan University of Medical Sciences; Poznan; Poland
| | - A. Mol
- Department of Microbiology; Poznan University of Medical Sciences; Poznan; Poland
| | - A. Nowicki
- Department of Hematology; Poznan University of Medical Sciences; Poznan; Poland
| | - A. Schneider
- Department of Microbiology; Poznan University of Medical Sciences; Poznan; Poland
| | - M. Komarnicki
- Department of Hematology; Poznan University of Medical Sciences; Poznan; Poland
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Antimicrobial therapy of febrile complications after high-dose chemotherapy and autologous hematopoietic stem cell transplantation--guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Hematol 2012; 91:1161-74. [PMID: 22638755 DOI: 10.1007/s00277-012-1456-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 03/16/2012] [Indexed: 01/29/2023]
Abstract
More than 18,000 autolgous transplantation were performed in Europe in the year 2009. It as a routine procedure in experienced centres. Even if there is a low mortality rate, infections are a major issue after transplantation, occurring in more than 60 % of the patients. In this review we discuss all aspects of infections after autologous stem transplantation, including epidemiology, diagnostics, therapeutic algorithms, prophylaxis and supportive therapy.
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Gupta S, Kapoor S, Ravi RNM, Prakash A, Aggarwal SK. Rectal involvement in neutropenic enterocolitis. Indian J Pediatr 2012; 79:535-7. [PMID: 21706240 DOI: 10.1007/s12098-011-0506-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 06/10/2011] [Indexed: 12/30/2022]
Abstract
Neutropenic enterocolitis is a common gastrointestinal complication in children undergoing chemotherapy for a variety of malignancies. It usually involves ileum and caecum, and involvement of rectum has rarely been reported. The authors report neutropenic enterocolitis in a child undergoing chemotherapy for acute lymphoblastic lymphoma which presented with ileus along with a mass like lesion in the rectum.
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Affiliation(s)
- Shuchita Gupta
- Department of Pediatrics, MAMC and Associated Lok Nayak Hospital, New Delhi, India
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Abstract
Gastrointestinal (GI) manifestations of leukemia occur in up to 25% of patients at autopsy, generally during relapse. Its presence varies with the type of leukemia and has been decreasing over time due to improved chemotherapy. Gross leukemic lesions are most common in the stomach, ileum, and proximal colon. Leukemia in the esophagus and stomach includes hemorrhagic lesions from petechiae to ulcers, leukemic infiltrates, pseudomembranous esophagitis, and fungal esophagitis. Lesions in the small and large bowel are usually hemorrhagic or infiltrative. Infiltration of lymphoreticular organs, mainly spleen, liver, and lymph nodes, is more prominent in chronic than acute leukemia. Neutropenic enterocolitis, a necrotizing process involving the cecum, ascending colon, and terminal ileum, is increasing in incidence due to greater intensity of chemotherapy. Distension of bowel leads to mucosal breaches, permitting entry of organisms that grow profusely in the absence of neutrophils. Ischemic necrosis follows, leading to perforation and/or peritonitis. Patients present with fever, abdominal pain, diarrhea, nausea, vomiting, abdominal distension and tenderness. Ultrasound and computed tomography scans show thickening of the bowel wall. Treatment is supportive with surgery for necrosis and perforation. The main GI causes of death in leukemia are hemorrhage, infection, and necrotizing enterocolitis.
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Affiliation(s)
- Ellen C Ebert
- Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
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Can first cycle CBCs predict older patients at very low risk of neutropenia during further chemotherapy? Crit Rev Oncol Hematol 2011; 79:43-50. [DOI: 10.1016/j.critrevonc.2010.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 03/02/2010] [Accepted: 07/07/2010] [Indexed: 11/19/2022] Open
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Abstract
Evaluation and management of acute abdominal pain in special populations can be challenging for the emergency physician. This article focuses on two specific populations: patients with altered immunologic function and postprocedural patients. Recognition of life-threatening abdominal diseases may be delayed in immunosuppressed patients because of the atypical presentations of these conditions. In postprocedural patients, evaluation of acute abdominal symptoms requires an understanding of the complications of procedures often performed by others. The unique characteristics of abdominal pain in these two populations and, more specifically, which diseases to consider and how to use appropriate testing to detect life-threatening conditions, are discussed.
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Affiliation(s)
- Esther H Chen
- Department of Emergency Medicine, University of San Francisco, San Francisco General Hospital, San Francisco, CA 94110, USA.
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Krishna SG, Zhao W, Grazziutti ML, Sanathkumar N, Barlogie B, Anaissie EJ. Incidence and risk factors for lower alimentary tract mucositis after 1529 courses of chemotherapy in a homogenous population of oncology patients: clinical and research implications. Cancer 2011; 117:648-655. [PMID: 20862749 DOI: 10.1002/cncr.25633] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 07/06/2010] [Accepted: 08/06/2010] [Indexed: 12/27/2022]
Abstract
BACKGROUND Lower alimentary tract mucositis is a serious complication of chemotherapy. The aim of the study was to determine the incidence, risk factors, and mortality of lower alimentary tract mucositis in a homogeneous population of patients with newly diagnosed myeloma receiving similar antineoplastic therapy and standardized supportive care. METHODS Lower alimentary tract mucositis was evaluated among 303 consecutive patients with myeloma (2004-2007) enrolled in a clinical trial consisting of induction chemotherapy, tandem melphalan-based autologous stem cell transplantation (ASCT), and consolidation. Lower alimentary tract mucositis was defined as neutropenia-associated grade II-IV enteritis/colitis. Pretreatment risk factors were examined including body surface area (BSA), serum albumin (albumin), and estimated creatinine clearance (CrCl). Multiple logistic regression model was used to compute adjusted odds ratio (OR) and 95% confidence intervals (CI). RESULTS Forty-seven (15.5%) patients developed lower alimentary tract mucositis during 1529 courses of chemotherapy (including 536 melphalan-based ASCT). Pre-enrollment BSA <2 m² (OR, 2.768; 95% CI, 1.200-6.381; P = .0169) increased the risk for lower alimentary tract mucositis, whereas higher albumin was protective (OR, 0.698; 95% CI, 0.519-0.940; P = .0177). Pretransplant variables associated with lower alimentary tract mucositis were BSA <2 m² (OR, 4.451; 95% CI, 1.459-13.58, P = .0087) and estimated CrCl <60 mL/min (OR, 3.493; 95% CI, 1.173-10.40; P = .0246). Higher albumin level conferred protection (OR, 0.500; 95% CI, 0.304-0.820; P = .0061). No lower alimentary tract mucositis-related death was observed. CONCLUSIONS Lower alimentary tract mucositis is not uncommon among a homogenous population of oncology patients undergoing sequential courses of chemotherapy including melphalan-based ASCT but does not contribute to mortality. Lower BSA, renal function, and albumin are associated with increased risk for lower alimentary tract mucositis.
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Affiliation(s)
- Somashekar G Krishna
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Abstract
Neutropenic enterocolitis or typhlitis (from the Greek word typhlon, meaning cecum) is a clinical syndrome that occurs in the setting of disease or chemotherapy-induced neutropenia. The disease is characterized by an inflammatory process involving colon and/or small bowel, and it can result in ischemia, necrosis, bacteremia, hemorrhage, and perforation. The classic clinical features include fever and abdominal pain. The diagnosis is supported by the findings of bowel wall thickening on ultrasonography or CT imaging. The management of neutropenic enterocolitis is controversial. Neither prospective nor high-quality retrospective studies concerning medical or surgical therapies are available. Most authors will recommend initial conservative management with bowel rest, intravenous fluids, total parenteral nutrition, broad-spectrum antibiotics and normalization of neutrophil counts. Surgical intervention is recommended in the setting of obstruction, perforation, persistent gastrointestinal bleeding despite correction of thrombocytopenia and coagulopathy, and clinical deterioration.
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Affiliation(s)
- Marta L Davila
- Department of Gastrointestinal Medicine and Nutrition, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard-Unit 436, Houston, TX 77030-4009, USA.
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Marchetti O, Calandra T. Infections in the neutropenic cancer patient. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00073-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Abstract
Data on the risk factors for typhlitis in children with cancer are limited. The aim of the study was to define the epidemiologic and clinical features of typhlitis and to elucidate predisposing factors for its development. The medical records of pediatric patients with cancer who were diagnosed with typhlitis from 1995 to 2005 were reviewed for clinical, laboratory, and imaging findings. The results were compared with a group of patients with cancer but without typhlitis who were hospitalized during the same period. Of the 843 cancer patients, 42 (5%) had episodes of typhlitis; 32 of them (76%) were being treated for hematologic malignancies. The incidence was highest in patients with Burkitt's lymphoma (15%) and acute myeloblastic leukemia (12%). Work-up included abdominal x-ray in all patients; abdominal ultrasonography and computed tomography were performed in 23% and 11% of patients, respectively. No cases were missed by plain x-ray when compared with computed tomography and ultrasonography. The typhlitis was treated without surgery and survival was 100%. On multivariate analysis, mucositis [odds ratio (OR) = 30.7], stem cell transplantation (OR = 58.9), and receipt of chemotherapy in the previous 2 weeks (OR = 12.9) were significantly associated with the occurrence of typhlitis. We conclude that most children with typhlitis may be treated without surgery in most cases with favorable outcome. A high index of suspicion may be warranted in patients after stem cell transplantation or chemotherapy and patients with mucositis.
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Ullery BW, Pieracci FM, Rodney JRM, Barie PS. Neutropenic enterocolitis. Surg Infect (Larchmt) 2009; 10:307-14. [PMID: 19566419 DOI: 10.1089/sur.2008.061] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Neutropenic enterocolitis, sometimes called typhilitis, is the most common gastrointestinal infection related to neutropenia, but its rarity, confusing terminology, and protean, non-specific manifestations result in variable approaches to diagnosis and management. METHODS Review of pertinent English-language literature. RESULTS The true incidence of neutropenic enterocolitis is unknown, but may be 5% or more among adult patients receiving chemotherapy for solid malignant tumors. The incidence is reported to be slightly lower in children. Estimates are made complex by recent recognition that neutropenia of any cause may be associated with enterocolitis; reports of non-chemotherapy drug-associated cases are increasing. Mortality rates are reported currently to be between 30% to 50%. The exact pathogenesis is also unknown, and may contribute to the varied nomenclature in use. Gut mucosal ulcerations may result from direct drug-related cytotoxicity, or from neutropenia itself. Microbial invasion of the bowel wall proceeds unimpeded. Pathological changes include inflammation and edema, presumably followed by ulceration, transmural necrosis, and perforation. The classic clinical presentation consists of fever, abdominal pain, and neutropenia, but diagnosis is often hindered by subtle or non-specific clinical findings, making computed tomography the linchpin of diagnosis. The wide spectrum of clinical presentation requires an individualized approach to therapy. Medical management, including administration of granulocyte colony-stimulating factor, may be appropriate for patients who do not have gastrointestinal bleeding, peritonitis, or intestinal perforation. Surgical management is generally reserved for patients who fall into any of the exceptional categories, and consists usually of bowel resection and stoma creation. CONCLUSIONS Neutropenic enterocolitis is a heterogeneous diseazse state with the capacity to affect many areas of the gastrointestinal tract, and disease severity that ranges from mild to fatal. A high index of suspicion is needed for all patients who present with fever and abdominal pain in the setting of neutropenia. Early detection allows a majority of cases to resolve with nonoperative management and supportive care, but surgical intervention is mandatory for peritonitis, bowel perforation, or gastyrointestinal hemorrhage that persists despite correction of coagulopathy.
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Affiliation(s)
- Brant W Ullery
- Department of Surgery, Weill Cornell Medical College, New York, New York 10021, USA
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Slavin MA, Grigg AP, Schwarer AP. Fatal Anerobic Bacteremia after Hematopoietic Stem Cell Transplant. Leuk Lymphoma 2009; 45:143-5. [PMID: 15061211 DOI: 10.1080/1042819031000149449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We describe 3 cases of fatal but clinically unsuspected anerobic bacteremia amongst hematopoietic stem cell transplant (HSCT) recipients treated empirically for fever and neutropenia with third or fourth generation cephalosporins. All patients had diarrhea but none had classical findings of neutropenic enterocolitis. HSCT recipients with fever, neutropenia and gastrointestinal tract symptoms such as abdominal pain or diarrhea or with septic shock despite broad spectrum antibiotics should receive an antimicrobial agent with anerobic activity.
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Affiliation(s)
- Monica A Slavin
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia.
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Ultrasound findings guided a successful hemicolectomy in a leukemic patient with neutropenic enterocolitis. J Ultrasound 2008; 11:97-101. [PMID: 23396752 DOI: 10.1016/j.jus.2008.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Neutropenic enterocolitis (NEC) can be a life-threatening complication of chemotherapy in leukemic patients. Early diagnosis and treatment is therefore crucial. METHODS A 38-year-old woman with acute lymphoblastic leukemia and chemotherapy-induced neutropenia suddenly developed symptoms suspicious of NEC. Transabdominal ultrasound showed features consistent with NEC, later confirmed by computed tomography (CT) scan. RESULTS The patient was scanned using portable ultrasound (US) equipment (Esaote My Lab 25). US findings showed involvement of the cecum, appendix, ascending colon and proximal middle transverse colon, with features resembling gas containing fissures within the colon wall itself. The risk of colon rupture was confirmed by CT scan. The patient underwent successful hemicolectomy after intravenous treatment with broad spectrum antibiotics, granulocyte-colony stimulating factor (G-CSF), platelets and fresh frozen plasma transfusion. DISCUSSION A prompt bedside US examination upon development of symptoms allowed an early diagnosis of NEC and identified features consistent with imminent colon wall rupture, shifting the management of this life-threatening complication from medical to surgical. Multidisciplinary intervention was crucial for a successful hemicolectomy in a severely affected neutropenic patient.
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Surgical Emergencies. Oncology 2007. [DOI: 10.1007/0-387-31056-8_73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Lee SY, Lin JH, Lai CT, Chang KS, Shih SC. Acute Abdomen in Post-chemotherapy Acute Monoblastic Leukemia. INT J GERONTOL 2007. [DOI: 10.1016/s1873-9598(08)70041-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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