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Differences between first and subsequent fevers during prolonged neutropenia
Abstract:
Fever during neutropenia before engraftment was studied in 86 consecutively treated patients undergoing allogeneic bone marrow transplantation. Eighty-four of the 86 patients experienced 132 febrile episodes. Only 26% of the patients had one fever which resolved with antibiotics. The rest required modification of antimicrobial therapy because of refractory fever (32%) or recurrent fevers (42%). The 121 fevers which occurred during neutropenia were analyzed to determine differences between first and subsequent fevers (79 and 42 episodes, respectively). The frequency of sepsis (23%) and defervescence (64%) did not differ between first and subsequent fevers. Presumed localized infection (PLI) was identified in 75% of first fever but in only 28% of subsequent fevers (P = 0.000002). Of the PLI identified, oropharyngeal mucosal disease accounted for 68% during first fever but only 38% during subsequent fevers (P = 0.02). Although sepsis in first fever was more frequently associated with PLI than sepsis in subsequent fevers (61% versus 10%, P = 0.01), overall, patients with PLI had a lower frequency of sepsis than those without (17% versus 32%, P = 0.04). Gram-negative pathogens were uniformly gentamicin sensitive in sepsis during first fever but were mostly gentamicin-resistant in sepsis during subsequent fevers (P = 0.01).
Insights
Fever during neutropenia in bone marrow transplant patients often requires antimicrobial therapy changes. Subsequent fevers are less likely to be localized infections and may involve gentamicin-resistant Gram-negative pathogens.
Area of Science:
- Hematology
- Infectious Diseases
- Transplantation Medicine
Background:
- Fever is a common complication in patients undergoing allogeneic bone marrow transplantation (BMT).
- Neutropenia, a state of low white blood cell count, increases the risk of infection.
- Understanding fever patterns and causes is crucial for effective patient management post-BMT.
Purpose of the Study:
- To analyze febrile episodes in neutropenic patients before engraftment following allogeneic BMT.
- To compare characteristics of first febrile episodes versus subsequent fevers.
- To identify differences in infection types, pathogens, and antibiotic resistance patterns.
Main Methods:
- Retrospective analysis of 86 consecutively treated patients undergoing allogeneic BMT.
- Detailed review of 132 febrile episodes occurring during neutropenia.
- Comparison of first (n=79) versus subsequent (n=42) fevers, analyzing presumed localized infection (PLI) and sepsis.
Main Results:
- Most patients (84/86) experienced febrile episodes requiring antimicrobial therapy modification.
- Subsequent fevers were significantly less likely to be identified as PLI (28% vs 75%) compared to first fevers.
- Gram-negative pathogens in sepsis during subsequent fevers showed increased gentamicin resistance (P=0.01).
Conclusions:
- Fever management in neutropenic BMT patients frequently necessitates antimicrobial therapy adjustments.
- Oropharyngeal mucosal disease was a common cause of first fevers, but less so for subsequent fevers.
- Shifting patterns of infection and increasing antibiotic resistance in subsequent fevers highlight the need for vigilant monitoring and tailored antimicrobial strategies.