Reply to Caldwell et al.
Reply to Caldwell et al.
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回复考德威尔等人。
DOI：
10.1093/cid/ciab1001
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发表时间：
2022
期刊：
影响因子：
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通讯作者：
Je
中科院分区：
文献类型：
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作者：
Satlin,MichaelJ;Chen,Liang;Douglass,Claire;Hovan,Michael;Davidson,Emily;Soave,Rosemary;LaSpina,Marisa;Gomez-Arteaga,Alexandra;vanBesien,Koen;Mayer,Sebastian;Phillips,Adrienne;Hsu,JingMei;Malherbe,Rianna;Small,CatherineB;Je
本研究的一个主要限制是中性粒细胞减少患者发生菌血症风险的指标没有报告，因此无法比较接受氟喹诺酮类药物预防治疗和未接受氟喹诺酮类药物预防治疗的患者发生菌血症风险。预计，尽管使用了氟喹诺酮类药物预防，但发生的突破性感染更有可能是由氟喹诺酮类药物耐药细菌引起的，而不是不使用氟喹诺酮类药物预防。然而，氟喹诺酮预防仍可降低菌血症的总体风险。我们之前比较了在我们中心接受自体HCT的多发性骨髓瘤患者在开始左氧氟沙星预防治疗前后发生菌血症的风险。我们发现，在开始左氧氟沙星预防后，对氟喹诺酮类药物耐药的肠杆菌血液分离株的比例从9%增加到73%。然而，在开始左氧氟沙星预防后，任何血液感染的风险从41%下降到15%，接受左氧氟沙星预防的患者发生革兰氏阴性菌血症、革兰氏阳性菌血症、发热和中性粒细胞减少的可能性较小。因此，尽管氟喹诺酮预防后发生的感染更有可能是由氟喹诺酮耐药细菌引起的，但氟喹诺酮预防仍可能降低感染和发烧的总体风险，这反过来可能降低败血症和使用广谱β-内酰胺治疗的风险。在高危中性粒细胞减少患者中不应普遍采用或停止氟喹诺酮类药物预防，我们最近发表的文章建议，在对携带氟喹诺酮耐药肠杆菌（FQRE） bbb进行筛查的情况下，使用氟喹诺酮类药物预防可能是首选的个体化预防方法。在这项接受左氧氟沙星预防的HCT受体研究中，移植时未定植FQRE的患者中只有1%出现突破性革兰氏阴性菌血症，而FQRE定植的患者中有31%，这表明氟喹诺酮预防的有效性取决于移植前FQRE的定植。我们目前正在进行一项多中心观察性研究，以在其他医疗中心和更广泛的血液病患者中验证这些发现，目标是制定一种个性化的方法来预防中性粒细胞减少患者的细菌感染。
A major limitation of this study is that the denominator of neutropenic patients who were at risk of developing bacteremia was not reported, preventing a comparison of the risk of bacteremia between patients who did and did not receive fluoroquinolone prophylaxis. It is expected that breakthrough infections that occur despite fluoroquinolone prophylaxis will be more likely to be caused by fluoroquinolone-resistant bacteria than those that occur in the absence of fluoroquinolone prophylaxis. However, fluoroquinolone prophylaxis may still decrease the overall risk of bacteremia. We previously compared the risk of bacteremia in patients with multiple myeloma undergoing autologous HCT at our center before and after the initiation of levofloxacin prophylaxis [7]. We found that the proportion of Enterobacterales bloodstream isolates that were fluoroquinolone resistant increased from 9% to 73% after the initiation of levofloxacin prophylaxis. However, the risk of any bloodstream infection decreased from 41% to 15% after initiation of levofloxacin prophylaxis and patients who received levofloxacin prophylaxis were less likely to develop gram-negative bacteremia, gram-positive bacteremia, and fever and neutropenia. Thus, although infections that occur despite fluoroquinolone prophylaxis are more likely to be caused by fluoroquinolone-resistant bacteria, fluoroquinolone prophylaxis may still decrease the overall risk of infection and fever, which in turn may decrease the risk of sepsis and use of broad-spectrum β-lactam therapies. Instead of universal adoption or cessation of fluoroquinolone prophylaxis in high-risk neutropenic patients, our recent publication suggests an individualized approach to prophylaxis may be preferred, where the decision to use fluoroquinolone prophylaxis is based on screening for carriage of fluoroquinoloneresistant Enterobacterales (FQRE)[8]. In this study of HCT recipients who received levofloxacin prophylaxis, only 1% of patients who were not colonized with FQRE at the time of transplantation had breakthrough gram-negative bacteremia, compared with 31% of patients colonized with FQRE, suggesting that the effectiveness of fluoroquinolone prophylaxis depends on pretransplant FQRE colonization. We are currently conducting a multicenter observational study to validate these findings at other medical centers and in a broader range of hematologic patients, with the goal of crafting an individualized approach to prevention of bacterial infections in neutropenic patients.