Review
The epidemiology and treatment of infections in cancer patients☆

https://doi.org/10.1016/j.ijantimicag.2007.06.014Get rights and content

Abstract

Significant changes in the epidemiology of infectious complications in cancer patients have emerged during the past decade. Among blood culture isolates from febrile neutropenic patients, Gram-positive pathogens have become predominant, and an increasing spread of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci must be taken into consideration. Risk factors such as indwelling venous catheters or chemotherapy-induced mucosal damage are associated with an increased incidence of Gram-positive infections. Invasive fungal infections, particularly invasive aspergillosis, have become most important in severely neutropenic patients and are associated with fatality rates of 40–60%. The use of nucleoside analogues and the CD52-antibody alemtuzumab induce a long-lasting lymphopenia facilitating the occurrence of opportunistic infections specifically caused by viruses and fungi. In elderly patients undergoing intensive myelosuppressive chemotherapy, infectious complications may be managed as successfully as in younger patients by appropriate antimicrobial therapy. The broad use of fluoroquinolones for antibacterial prophylaxis in neutropenic patients may lead to very high resistance rates among Gram-negative bacilli such as E. coli. In patients given moxifloxacin for infection prevention, unacceptably large numbers of Clostridium difficile-associated enterocolitis have been reported.

Introduction

Infections are a major cause of morbidity and mortality in cancer patients undergoing antineoplastic treatment. Prompt empiric antimicrobial treatment is mandatory in patients with severe neutropenia (i.e. polymorphonuclear neutrophils below 500 per microlitre) and fever not clearly attributable to non-infectious causes. The selection of antimicrobial agents in patients without a clinically identified focus of infection and without microbiological evidence of infection, i.e. ‘fever of unknown origin (FUO)’ is based upon the spectrum of pathogens detected in microbiologically proven infections as well as on success rates reported from clinical studies on empirical antimicrobial therapy in neutropenic patients with FUO [1], [2].

In patients with a clinically identified source of infection, such as an inflammation at the insertion site of a venous catheter, a lung infiltrate, an abdominal or a perianal focus, the spectrum of typically involved microorganisms can be further specified, so that the selection of antimicrobial can be done on a pre-emptive basis [3]. This short review will describe some important changes in the epidemiology of infections in cancer patients that have emerged during the past decade.

Section snippets

Bloodstream infections

A considerable shift in the spectrum of pathogens isolated from blood cultures of febrile neutropenic cancer patients in the USA has emerged since 1995 [4], with Gram-positive cocci increasing from 62% to 76% of isolates, Gram-negative bacilli declining from 21.5% to 14%, and fungi declining from 15% to 8%. From consecutive clinical trials conducted by the European Organization on the Research and Treatment of Cancer (EORTC) between 1973 and 2000, a shift toward the predominance of

Invasive fungal infections

With the marked improvement of the antimicrobial armamentarium against formerly fatal bacterial infections, invasive mycoses have become leading causes of morbidity and mortality in cancer patients [10], [11]. The highest incidence of infections due to filamentous fungi (predominantly Aspergillus spp., and less frequently zygomycetes) has been reported for patients with acute myeloid leukaemia, in whom the rate of ‘mould’ infections is in the order of 7.9%, and of yeast infections around 4.4%

Nucleoside analogues

Nucleoside analogues, specifically fludarabine, have become standard agents for primary therapy of indolent B-cell lymphomas such as chronic lymphocytic leukaemia, Waldenström's macroglobulinaemia and hairy cell leukaemia since the early 1990s. These agents induce a profound depletion of CD4+ T cells lasting for up to 6 months and beyond. In patients with B-CLL treated with fludarabine for relapse, the rate of opportunistic infections was as high as 58%, while after upfront treatment with

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    ☆

    This work was in part presented at the 25th International Congress on Chemotherapy held together with the 17th European Congress on Clinical Microbiology and Infectious Diseases in Munich, Germany, 31 March–3 April, 2007.

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