Patient d'oncohématologie neutropénique fébrile admis en réanimation, recommandations actuelles et attitude pratique

Febrile neutropenia in cancer patients is associated with a high mortality. In this situation, empirical antibiotic treatment must be prompt and cover the common pathogens. Gram-positive infections occur frequently in neutropenic patients, whereas Gram-negative infections are associated with a higher mortality. Up to now, an empirical treatment with a β-lactam in combination with an aminoglycoside represented the most used antibiotic regimen. Recent studies and recommendations demonstrate that monotherapy with β-lactam is as efficacious and less toxic than β-lactam-aminoglycoside combination as empirical treatment. Combination therapy should be kept for patients developing severe sepsis, septic shock or for those with a high suspicion of resistant Gram-negative infections. Glycopeptide antibiotics should be prescribed for patients having severe sepsis, septic shock, high suspicion of skin or soft tissue infections (including catheter tunnel infection) and in a context of local epidemiology of resistant Gram-positive bacteria. Empirical antifungal therapy should be introduced empirically in patients who remain neutropenic and febrile for five days or more despite the administration of broad-spectrum antibiotics as recommended. Systematic reassessment of initial antibiotic regimen should be realised in order to control local microbiological epidemiology and the emergence of multiresistant bacteria.