Fieber unklarer Genese (FUO) bei Kindern und Jugendlichen mit onkologischen Erkrankungen

 

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Zusammenfassung

Die Einführung einer unverzüglich begonnenen empirischen intravenösen Antibiotikatherapie hat die Letalität von onkologisch erkrankten Patienten mit Fieber während der Granulozytopenie deutlich gesenkt. So ist bei Sepsis mit Gramnegativen Erregern die Letalität von 84 % in den 1960er-Jahren auf 3-10 % in aktuellen Untersuchungen reduziert worden. Allerdings erlaubt die initiale klinische Präsentation des Patienten nur selten eine eindeutige Einschätzung hinsichtlich der Schwere des weiteren klinischen Verlaufes. Auch der weitere Verlauf führt nur in etwa der Hälfte der Patienten zu einer klinischen oder mikrobiologischen Diagnose, so dass etwa 50 % der Patienten mit Fieber unbekannter Ursache (FUO) behandelt werden. Während für die Behandlung internistisch onkologischer Patienten Leitlinien zur Therapie des FUO auf der Grundlage von Studien existieren, ist die Datenlage für onkologisch erkrankte Kinder und Jugendliche deutlich schlechter. Die Einleitung der empirischen Therapie mit einem Pseudomonas-wirksamem Antibiotikum wird allgemein anerkannt. Wenig umstritten ist auch die stationäre Aufnahme der Patienten und der sofortige Beginn der intravenösen antibiotischen Therapie, ohne den Erregernachweis abzuwarten. Unklarheiten bestehen jedoch hinsichtlich der Indikation einer Therapie mit Aminoglykosiden und Glykopeptiden. Auch Therapiedauer und die Notwendigkeit der Antibiotika-Ergänzung und -Umstellung werden uneinheitlich gehandhabt. Auf der Grundlage von Studien an onkologisch erkrankten Erwachsenen und soweit verfügbar auch von Kindern und Jugendlichen, werden die oben genannten offenen Fragen dargestellt und diskutiert. Die daraus resultierenden Empfehlungen werden für Kinder und Jugendliche angepasst. Dabei sind lokale Erregerspektren einzubeziehen.

Abstract

The rapid institution of empirical broad-spectrum antibiotics has become the gold standard of treatment for febrile neutropenic children undergoing therapy for cancer. With this approach, morbidity and mortality have dropped significantly but have not been eliminated altogether. In recent randomized studies evaluating different drug combinations, there is still a 3-10 % mortality reported in febrile, neutropenic cancer events. Despite improvements in invasive and non-invasive diagnostic procedures, a majority of patients will receive antibiotic therapy despite an inability to identify a specific pathogen or source (fever of unknown origin, FUO). While there are evidence-based guidelines in adult patients with fever and neutropenia, data are less clear in the pediatric population. Experts agree on the early use of empirical antibiotic therapy, which covers Pseudomonas spp. and is initiated at the first sign of fever. The success of this approach has been based upon clinical intervention before the results of the diagnostic evaluation are available. In contrast, the use of aminoglycosides or glycopeptides is still a matter of debate, as it is the duration of antibiotic therapy. Based on published data in pediatric and adult patients with cancer, the current diagnostic procedures and therapeutic strategies will are discussed. The recommendations given are a consensus of the German Society of Pediatric Oncology and Hematology (GPOH) and the German Society of Pediatric Infectious Diseases (DGPI).

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Dr. Hans-Jürgen Laws

Klinik für Kinder-Onkologie, -Hämatologie und -Immunologie

Moorenstr. 5

40225 Düsseldorf

Email: laws@med.uni-duesseldorf.de