Intervention Review
Additional anti-Gram-positive antibiotic treatment for febrile neutropenic cancer patients
Editorial Group: Cochrane Gynaecological Cancer Group
Published Online: 17 MAR 2010
Assessed as up-to-date: 14 AUG 2007
DOI: 10.1002/14651858.CD003914.pub2
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Database Title
Additional Information
How to Cite
Paul M, Borok S, Fraser A, Vidal L, Cohen M, Leibovici L. Additional anti-Gram-positive antibiotic treatment for febrile neutropenic cancer patients. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD003914. DOI: 10.1002/14651858.CD003914.pub2.
Publication History
- Publication Status: Edited (no change to conclusions)
- Published Online: 17 MAR 2010
Abstract
Background
The pattern of infections among neutropenic cancer patients has shifted in the last decades to a predominance of Gram-positive infections. Some of these Gram-positive bacteria are increasingly resistant to beta-lactams and necessitate specific antibiotic treatment.
Objectives
To assess the effectiveness of empirical anti-Gram-positive (antiGP) antibiotic treatment for febrile neutropenic cancer patients in terms of mortality and treatment failure. To assess the rate of resistance development, further infections and adverse events associated with additional antiGP treatment.
Search methods
We searched The Cochrane Central Register of Controlled Tirals (CENTRAL), (The Cochrane Library Issue 3, 2007), PUBMED (1966 to 2007), LILACS (1982 to 2007), conference proceedings, and all references of included studies. First authors of all included and potentially relevant trials were contacted.
Selection criteria
Randomised controlled trials (RCTs) comparing one antibiotic regimen to the same regimen with the addition of an antiGP antibiotic for the treatment of febrile neutropenic cancer patients.
Data collection and analysis
Two review authors independently assessed trial eligibility, methodological quality and extracted all data. Relative risks (RR) with 95% confidence intervals (CI) were calculated. A random effects model was used for all comparisons showing substantial heterogeneity (I
Main results
Thirteen trials and 2392 patients or episodes were included. Empirical antiGP antibiotics were tested at the onset of treatment in eleven studies and for persistent fever in two studies. The antiGP treatment was a glycopeptide in nine trials. Seven studies were assessed in the overall mortality comparison and no significant difference between the comparator arms was seen, RR 0.82 (95% CI 0.56 to 1.20, 852 patients). Ten trials assessed failure including modifications as failures, while six assessed overall failure, disregarding treatment modifications. Failure with modifications was significantly reduced, RR 0.76 (95% CI 0.68 to 0.85, 1779 patients) while overall failure was equal, RR 1.00, 95% CI (0.79 to 1.27, 943 patients). Both mortality and failure did not differ significantly among patients with Gram-positive infections, but comparisons were small. Data regarding other patient subgroups likely to benefit from antiGP treatment were not available. Glycopeptides did not increase fungal superinfection rates, and were associated with a reduction in documented Gram-positive superinfections. Resistant colonisation was not documented in the studies.
Authors' conclusions
Current evidence shows that the addition of antiGP treatment, namely glycopeptides, prior to documentation of a Gram-positive infection does not improve outcomes.
Plain language summary
Specific antibiotic treatment directed against resistant Gram-positive bacteria can await identification of these pathogens and need not be given empirically
Resistant Gram-positive bacteria, originating from the skin and breaks in skin integrity such as intravenous lines, have emerged as causes for infection in cancer patients. Specific antibiotics must be added to the 'standard' antibiotic regimen to cover these bacteria. The review authors identified 13 randomised controlled trials using antibiotic treatments administered prior to identifying a causative pathogen, which compared those including or excluding specific anti-Gram positive antibiotics. Mortality and several morbidity measures following infection did not differ significantly. These specific antibiotics are 'last resort' antibiotics against infections due to Gram-positive bacteria and their use in general should be restricted to proven infections.
摘要
背景
用於治療發燒性嗜中性球減少性癌症病患之額外抗革蘭氏陽性菌抗生素的治療
在過去數十年間，嗜中性球減少性癌症病患之感染模式已經改變為主要係革蘭氏陽性菌感染。部分此等革蘭氏陽性菌對於β內醯胺日益具有抗藥性，並因此需要特定之抗生素治療。
目標
評估發燒性嗜中性球減少性癌症病患之經驗性抗革蘭氏陽性菌 (抗GP) 抗生素治療就死亡率及治療失敗率而言之有效性。評估與增添抗GP治療有關之抗藥性發生率、進一步之感染、以及不良副作用。
搜尋策略
我們搜尋了Cochrane Central Register of Controlled Tirals (CENTRAL), (The Cochrane Library Issue 3, 2007) 、PUBMED (1966年至2007年) 、LILACS (1982年至2007年) 、研討會論文集、以及收錄研究之所有參考資料。亦聯繫所有收錄及潛在相關試驗之第一作者。
選擇標準
針對發燒性嗜中性球減少性癌症病患之治療，比較抗生素療程及增添抗GP抗生素之該相同療程的隨機對照試驗 (RCTs) 。
資料收集與分析
由2名回顧作者評估試驗之適用性、方法學品質、並摘錄所有數據。計算相對風險 (RR) 及95% 信賴區間 (CI) 。針對顯示實質異質性 (I2 >50%) 之所有比較使用隨機效果模型。摘錄治療意向作為結果，並在可能時進行以病患為基礎之分析。
主要結論
收錄13項試驗以及2392名參與者或事件。經驗性之抗GP抗生素在其中11項研究之治療起始時給予，並在其中2項研究試驗在有持續性之發燒。該抗GP治療在其中9項試驗中為糖月太。其中7項研究評估整體死亡率之比較，並未發現比較組別間之顯著差異，RR 0.82 (95% CI 0.56 to 1.20, 852名病患) 。其中10項試驗評估治療失敗，將治療修正計在失敗之中，而其中6項則係評估整體失敗，不將治療修正納入考慮。包含修正之失敗可顯著減少，RR 0.76 (95% CI 0.68 to 0.85, 1779名病患) ，而整體失敗則為相同，RR 1.00, 95% CI (0.79 to 1.27, 943名病患) 。在革蘭氏陽性菌感染病患中死亡率及失敗率皆無顯著差異，但是比較皆為少量病患的群組。有關其他可能由抗GP治療獲益之病患亞群的數據並無法取得。糖月太並未增加真菌超感染率，且與革蘭氏陽性菌超感染之記錄減少有相關。在研究中並未記錄到抗藥性菌株之產生。
作者結論
現有之證據顯示，在記錄革蘭氏陽性菌感染前之額外抗GP治療 (亦即糖月太) 並無法改善病患結果。
翻譯人
此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。
總結
針對抗藥性革蘭氏陽性菌之特定抗生素治療可等到辨識出此等病原體之後再行給予，並不須根據經驗給予。 源自皮膚並由靜脈點滴管破壞皮膚完整性之抗藥性革蘭氏陽性菌已成為癌症病患感染的肇因之一。茲必須在「標準」之抗生素療程中加入特定抗生素以涵蓋此等細菌。本回顧之作者辨識出13項在辨識出肇因性病原體之前即使用抗生素治療之隨機對照試驗，該等試驗針對包括或排除特定抗藥性革蘭氏陽性菌抗生素者進行比較。感染後之死亡率以及數種病痛量測並未具有顯著差異。此等特定抗生素係對抗革蘭氏陽性菌感染之「最後手段」抗生素，且其使用一般而言應限於經證實之感染。