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Managing Infections in the Immunocompromised Patient

  1. Gerald P. Bodey
  1. Department of Infectious Diseases, M. D. Anderson Cancer Center, University of Texas, Houston
  1. Reprints or correspondence: Dr. Gerald P. Bodey, Dept. of Infectious Diseases, M. D. Anderson Cancer Center, University of Texas, Box 402, Houston, TX 77030 (gbodey{at}mdanderson.org).
 
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Abstract

Increasingly aggressive practices for treatment of patients with hematologic malignancies create challenges for successful management of infectious complications in immunocompromised patients. Infectious diseases practitioners face changing patterns of causative pathogens in their patients with febrile neutropenia, as well as evolving standards for empirical use of antimicrobial agents. The articles in this supplement issue of Clinical Infectious Diseases review these issues and their implications for current clinical practice.

After World War II, therapeutic agents that were effective against hematologic malignancies became available. It quickly became apparent that infectious complications caused by the myelosuppressive toxicities of those agents and the associated malignant processes were major impediments to successful treatment of patients with hematologic malignancies. The risk and severity of infection were shown to be related to the degree and duration of granulocytopenia, and recovery from granulocytopenia was a critical factor in a successful outcome [1]. In addition, early studies emphasized the importance of administering antibiotic therapy to patients with hematologic malignancies at the onset of fever [2, 3].

An important contribution to the successful treatment of infections in patients with neutropenia was the discovery of effective antimicrobial agents, most notably the broad-spectrum β-lactams. For example, carbenicillin reduced the mortality rate associated with septicemia due to Pseudomonas species from 80% to 25% [2]. Since the discovery of effective antimicrobial agents, new agents and regimens have continued to improve the prognosis for infected patients with neutropenia [4, 5]. Another important contribution has been the development of therapies using growth factor, which reduce the severity and duration of neutropenia. However, these successes have led to the use of more-intensive antitumor regimens that cause additional toxicities, such as severe mucositis and prolonged lymphopenia. Bone marrow transplantation has become an important therapy and is associated with a wide variety of infectious complications.

Thus, the challenges of managing infections in immunocompromised patients continue to evolve. The major issues for clinicians who provide supportive care for patients with febrile neutropenia are as follows: changes in predominant pathogens; institutional variations in microbiological and drug-resistance patterns; consequences of widespread use of broad-spectrum antibiotics for prophylaxis and therapy; selection of appropriate antibiotics, according to different levels of risk for serious infections in individual patients; and the potential for some antibiotic regimens to be superior to others. The articles in this supplement illustrate how these advances and issues affect the daily practice of infectious diseases specialists who provide supportive care for patients with cancer who also have fever and neutropenia.

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Acknowledgments

Financial support. The symposium Managing Infections in the Immunocompromised Patient and this supplement were supported by an unrestricted educational grant from Wyeth Pharmaceuticals.

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  1. Clin Infect Dis. (2005) 40 (Supplement 4): S239. doi: 10.1086/427328
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