[Antibiotherapy in the patient with granulocytopenic cancer]

Granulocytopenia is the leading alteration of the natural host defense mechanisms, whether caused by an underlying disease or associated with anticancer chemotherapy and radiation therapy. Severe granulocytopenia predisposes to septicemia which is now more often due to Gram positive than to Gram negative bacteria. The empiric therapy of febrile episodes with rapidly bactericidal antibiotics has dramatically modified the prognosis of septicemia. The optimal treatment remains controversial although the usual regimen include both a cephalosporin (or a large spectrum penicillin) with an aminoglycoside. The empiric treatment with a specific anti-Gram positive antibiotic such as vancomycin does not modify prognosis, adds significant side-effects and increases the cost. Monotherapy has been associated with the need for treatment modification in 30-80% of the episodes depending on the type of infection (fever of unknown origin, clinically or microbiologically documented infection). The patients who remain febrile despite adequate antibacterial empiric treatment beneficiate of an empiric antifungal treatment. Care should be taken about the recent emergence of vancomycin-resistant Staph. haemolyticus, Corynebacterium JK and non-JK, and non-aeruginosa pseudomonas (only susceptible to cotrimoxazole). More fungal infections are observed with a significant emergence of non-albicans Candida, dermatophytes and filamentous fungi (P. boydii, Fusarium, ...) associated with disseminated infections.