Personalized treatment of severe pneumonia in cancer patients

Abstract

Patients with cancer are at increased risk for sepsis as a consequence of immunosuppression. The hospital mortality remains elevated and it could be attributed to antibiotic failure because of the presence of multiresistant pathogens. Once the patient is critically ill, the use of the American Thoracic Society/Infectious Diseases Society of America classification does not seem very useful in the assessment of outcomes and the choice of antimicrobials. In critically ill patients, the characteristics of clinical response to antibiotics are usually inaccurate and occur late in the course of disease. So, the sequential evaluation of C-reactive protein-ratio is useful in the early identification of patients with antibiotic failure. To achieve safe and efficient antimicrobial therapy, we proposed an algorithm that may aid clinicians in their decision-making process.

Keywords:

• antimicrobial
• biomarker
• cancer
• multiresistant
• outcome
• pneumonia

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Patients with cancer are at increased risk for sepsis as a consequence of immunosuppression imposed by the disease itself and aggressive treatments.

• Critically ill cancer patients are more susceptible to multiresistant (MR) infections because of the intensive use of hospital care for anticancer treatments such as surgery, chemo- and radiation therapy as well as the use of antimicrobials.

• The concept of antibiotic stewardship progressively evolved to individualize prescriptions by the introduction of new concepts such as avoiding unnecessary administration of broad-spectrum antibiotics and promoting systematic de-escalation.

• The presence of risk factors to develop infection by MR pathogens is essential to guide antibiotic therapy for patients with severe pneumonia.

• The most important factors to assess the risk for MR pathogens were hospitalization in the preceding 90 days, residence in a nursing home or extended-care facility and comorbidities.

• Biomarkers (namely C-reactive protein and procalcitonin) are very useful in the assessment of response to antibiotic therapy and the identification of potential complications or other etiologies of pneumonia.

• The sequential evaluation of C-reactive protein ratio is useful in the early identification of patients with antibiotic failure.

• Critically ill cancer patients constitute a distinct subgroup of patients with severe pneumonia and the American Thoracic Society/Infectious Diseases Society of America classification does not seem to be useful in the antibiotic choice.