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Neutropenic Enterocolitis in Critically Ill Patients

Spectrum of the Disease and Risk of Invasive Fungal Disease

Duceau, Baptiste, MD1,2; Picard, Muriel, MD3; Pirracchio, Romain, PhD4,5; Wanquet, Anne, MD6; Pène, Frédéric, PhD7; Merceron, Sybille, MD8; Mokart, Djamel, PhD6; Moreau, Anne-Sophie, MD9; Lengliné, Etienne, MD10; Canet, Emmanuel, PhD1,2; Lemiale, Virginie, MD1,2; Mariotte, Eric, MD1,2; Azoulay, Elie, PhD1,2; Zafrani, Lara, PhD1,2

doi: 10.1097/CCM.0000000000003687
Clinical Investigations

Objectives: Neutropenic enterocolitis occurs in about 5.3% of patients hospitalized for hematologic malignancies receiving chemotherapy. Data from critically ill patients with neutropenic enterocolitis are scarce. Our objectives were to describe the population of patients with neutropenic enterocolitis admitted to an ICU and to investigate the risk factors of invasive fungal disease.

Design: A multicentric retrospective cohort study between January 2010 and August 2017.

Setting: Six French ICUs members of the Groupe de Recherche Respiratoire en Onco-Hématologie research network.

Patients: Adult neutropenic patients hospitalized in the ICU with a diagnosis of enteritis and/or colitis. Patients with differential diagnosis (Clostridium difficile colitis, viral colitis, inflammatory enterocolitis, mesenteric ischemia, radiation-induced gastrointestinal toxicity, and Graft vs Host Disease) were excluded.

Interventions: None.

Measurement and Main Results: We included 134 patients (median Sequential Organ Failure Assessment 10 [8–12]), with 38.8% hospital mortality and 32.1% ICU mortality rates. The main underlying malignancies were acute leukemia (n = 65, 48.5%), lymphoma (n = 49, 36.6%), solid tumor (n = 14, 10.4%), and myeloma (n = 4, 3.0%). Patients were neutropenic during a median of 14 days (9–22 d). Infection was documented in 81 patients (60.4%), including an isolated bacterial infection in 64 patients (47.8%), an isolated fungal infection in nine patients (6.7%), and a coinfection with both pathogens in eight patients (5.0%). Radiologically assessed enteritis (odds ratio, 2.60; 95% CI, 1.32–7.56; p = 0.015) and HIV infection (odds ratio, 2.03; 95% CI, 1.21–3.31; p = 0.016) were independently associated with invasive fungal disease.

Conclusions: The rate of invasive fungal disease reaches 20% in patients with neutropenic enterocolitis when enteritis is considered. To avoid treatment delay, antifungal therapy might be systematically discussed in ICU patients admitted for neutropenic enterocolitis with radiologically assessed enteritis.

1Medical Intensive Care Unit, Hospital Saint Louis, Assistance Publique–Hôpitaux de Paris, France.

2Paris Diderot University, Paris, France.

3Intensive Care Unit, CHU de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France.

4Anesthesiology and Surgical Intensive Care Unit, European Hospital Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France.

5Department of Biostatistics and Medical Informatics, INSERM U-1153, Paris, France.

6Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France.

7Medical Intensive Care Unit, Hospital Cochin, Assistance Publique–Hôpitaux de Paris, Paris, France.

8Intensive Care Unit, Centre Hospitalier de Versailles, Le Chesnay, France.

9Intensive Care Unit, Salengro Hospital, CHU-Lille, Lille, France.

10Department of Hematology, Hospital Saint Louis, Assistance Publique–Hôpitaux de Paris, Paris, France.

Drs. Duceau, Azoulay, and Zafrani conceptualized and designed the study. Drs. Picard, Wanquet, Pène, Merceron, Mokart, Moreau, Lengline, Canet, Lemiale, Mariotte, Azoulay, and Zafrani provided the study materials or patients. Drs. Duceau, Picard, Wanquet, Merceron, Moreau, and Zafrani collected and assembled the data. Drs. Duceau, Pirracchio, Azoulay, and Zafrani analyzed and interpreted the data, and wrote the article. All authors approved the final version of the article.

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Supported, in part, by the Groupe de Recherche Respiratoire en Réanimation Onco-Hematologique.

Dr. Azoulay’s institution received funding from Fisher and Paykel, Alexion, Gilead, Baxter, Jazz Pharma, and Ablynx, and he received funding from lecture fees from Alexion, Baxter, Gilead, Merck Sharpe & Dohme, and Astellas. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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