Infektionen in der pädiatrischen Hämatologie und Onkologie

Zusammenfassung

Trotz aller Fortschritte in der Supportivtherapie gehören Infektionen immer noch zu häufigen und potenziell lebensbedrohlichen Komplikationen bei krebskranken Kindern. Die Granulozytopenie ist der wichtigste Einzelrisikofaktor für Infektionen, jedoch bedingt die Therapie der Krebserkrankung eine komplexe Störung aller Arme des Immunsystems und macht die Kinder für eine Vielzahl von opportunistischen Keimen empfänglich. Heutzutage werden bei krebskranken Kindern überwiegend Grampositive Erreger isoliert, aber Gramnegative Erreger können binnen kürzester Zeit zu schwersten septischen Krankheitsbilden führen. Bei prolongierter Granulozytopenie steigt zudem das Risiko für eine Pilzinfektion. Während Fieber oft das einzige Zeichen einer Infektion ist, fehlen gerade in der Frühphase der Infektion meist spezifische klinische oder radiologische Zeichen. Da auch keine Laborparameter existieren, die frühzeitig und verlässlich eine Infektion anzeigen, erhalten heute alle Kinder mit Fieber bei Granulozytopenie eine empirische antibiotische Therapie. Eine Stratifizierung durch klinische oder genetische Risikofaktoren wird derzeit evaluiert, kann aber noch nicht allgemein empfohlen werden. Möglicherweise lässt sich hierdurch die Intensität der antimikrobiellen Prophylaxe entsprechend des individuellen Risikos des Patienten steuern sowie nur die Patienten, die tatsächlich Infektionen haben, rasch einer suffizienten und individuell angepassten Therapie zuführen.

Abstract

Infectious complications are still a major cause of morbidity and mortality in pediatric patients undergoing therapy for malignancy. Therapy-induced neutropenia is the most important risk factor for infectious risk in pediatric patients with cancer, but other factors, such as alterations in skin/mucosal barriers, and defects in cell-mediated or humoral immunity also contribute to the risk for infection. In most centers, about two thirds of bacteremic isolates are gram-positive pathogens, whereas gram-negative organisms are isolated less frequently, but are associated with considerably higher mortality rates. Prolonged neutropenia increases the risk for invasive fungal infection. In most cases, fever is an important and early indication of serious infection, particularly in children with neutropenia. Discrimination between serious and inconsequential infection in febrile children with neutropenia at the time of presentation is difficult, and serum markers have not been proven to reliably indicate infection. Although several groups investigate risk categories based on clinical tests or the genetic background, the current paradigm is to treat all pediatric patients with neutropenia and fever with intravenous broad-spectrum antibiotics. It is hoped that the identification of one or more predictive factors may be useful for tailoring antibiotic prophylaxis and therapy in children with cancer.

Schlüsselwörter

Krebserkrankungen - Kinder - Infektionen - Erreger - Risikofaktoren

Key words

cancer - child - infectious complication - pathogen - risk factor

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