Abstract
Objective
To compare the characteristics and outcome of patients with hematological malignancies referred to the ICU with severe sepsis and septic shock who had or had not received recent intravenous chemotherapy, defined as within 3 weeks prior to ICU admission.
Design and setting
Retrospective observational cohort study on prospectively collected data in a medical ICU of a university hospital.
Patients
186 ICU patients with hematological malignancies with severe sepsis or septic shock (2000–2006).
Measurements and results
There were 77 patients admitted with severe sepsis and 109 with septic shock; 91 (49%) had received recent intravenous chemotherapy. Patients with recent chemotherapy more often had a high-grade malignancy and were more often neutropenic, less often had pulmonary infiltrates, and less often required mechanical ventilation. ICU, 28-day, in-hospital, and 6-month mortality rates were 33% vs. 48.4%, 40.7% vs. 57.4%, 45.1% vs. 58.9%, and 50.5% vs. 63.2% in patients with and without recent chemotherapy, respectively. Logistic regression identified four variables independently associated with 28-day mortality: SOFA score at ICU admission, pulmonary site of infection, and fungal infection were associated with worse outcome whereas previous intravenous chemotherapy was protective at borderline significance. After adjustment with a propensity score for recent chemotherapy, chemotherapy was not associated with outcome.
Conclusions
Patients referred to the ICU with severe sepsis and septic shock complicating active chemotherapeutic treatment have better prognosis than commonly perceived.
Similar content being viewed by others
References
Brenner H (2002) Long-term survival rates of cancer patients achieved by the end of the 20th century: a period analysis. Lancet 360:1131–1135
Azoulay E, Afessa B (2006) The intensive care support of patients with malignancy: do everything that can be done. Intensive Care Med 32:3–5
Groeger JS, Bach PB (2003) Consider saying yes. Crit Care Med 31:320–321
Azoulay E, Thiery G, Chevret S, Moreau D, Darmon M, Bergeron A, Yang K, Meignin V, Ciroldi M, Le Gall JR, Tazi A, Schlemmer B (2004) The prognosis of acute respiratory failure in critically ill cancer patients. Medicine (Baltimore) 83:360–370
Benoit DD, Vandewoude KH, Decruyenaere JM, Hoste EA, Colardyn FA (2003) Outcome and early prognostic indicators in patients with a hematologic malignancy admitted to the intensive care unit for a life-threatening complication. Crit Care Med 31:104–112
Depuydt PO, Benoit DD, Vandewoude KH, Decruyenaere JM, Colardyn FA (2004) Outcome in noninvasively and invasively ventilated hematologic patients with acute respiratory failure. Chest 126:1299–1306
Soares M, Salluh JI, Spector N, Rocco JR (2005) Characteristics and outcomes of cancer patients requiring mechanical ventilatory support for > 24 hrs. Crit Care Med 33:520–526
Benoit DD, Depuydt PO, Peleman RA, Offner FC, Vandewoude KH, Vogelaers DP, Blot SI, Noens LA, Colardyn FA, Decruyenaere JM (2005) Documented and clinically suspected bacterial infection precipitating intensive care unit admission in patients with hematological malignancies: impact on outcome. Intensive Care Med 31:934–942
Hilbert G, Gruson D, Vargas F, Valentino R, Gbikpi-Benissan G, Dupon M, Reiffers J, Cardinaud JP (2001) Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 344:481–487
Thiery G, Azoulay E, Darmon M, Ciroldi M, De Miranda S, Levy V, Fieux F, Moreau D, Le Gall JR, Schlemmer B (2005) Outcome of cancer patients considered for intensive care unit admission: a hospital-wide prospective study. J Clin Oncol 23:4406–4413
Azoulay E, Alberti C, Bornstain C, Leleu G, Moreau D, Recher C, Chevret S, Le Gall JR, Brochard L, Schlemmer B (2001) Improved survival in cancer patients requiring mechanical ventilatory support: impact of noninvasive mechanical ventilatory support. Crit Care Med 29:519–525
Lecuyer L, Chevret S, Thiery G, Darmon M, Schlemmer B, Azoulay E (2007) The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med 35:808–814
Benoit DD, Hoste EA, Depuydt PO, Offner FC, Lameire NH, Vandewoude KH, Dhondt AW, Noens LA, Decruyenaere JM (2005) Outcome in critically ill medical patients treated with renal replacement therapy for acute renal failure: comparison between patients with and those without haematological malignancies. Nephrol Dial Transplant 20:552–558
Darmon M, Thiery G, Ciroldi M, de Miranda S, Galicier L, Raffoux E, Le Gall JR, Schlemmer B, Azoulay E (2005) Intensive care in patients with newly diagnosed malignancies and a need for cancer chemotherapy. Crit Care Med 33:2488–2493
Soares M, Salluh JI, Carvalho MS, Darmon M, Rocco JR, Spector N (2006) Prognosis of critically ill patients with cancer and acute renal dysfunction. J Clin Oncol 24:4003–4010
Benoit DD, Depuydt PO, Vandewoude KH, Offner FC, Boterberg T, De Cock CA, Noens LA, Janssens AM, Decruyenaere JM (2006) Outcome in severely ill patients with hematological malignancies who received intravenous chemotherapy in the intensive care unit. Intensive Care Med 32:93–99
Hughes WT, Armstrong D, Bodey GP, Bow EJ, Brown AE, Calandra T, Feld R, Pizzo PA, Rolston KV, Shenep JL, Young LS (2002) 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 34:730–751
Larche J, Azoulay E, Fieux F, Mesnard L, Moreau D, Thiery G, Darmon M, Le Gall JR, Schlemmer B (2003) Improved survival of critically ill cancer patients with septic shock. Intensive Care Med 29:1688–1695
Regazzoni CJ, Irrazabal C, Luna CM, Poderoso JJ (2004) Cancer patients with septic shock: mortality predictors and neutropenia. Support Care Cancer 12:833–839
Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med 30:536–555
Groeger JS, Lemeshow S, Price K, Nierman DM, White P Jr, Klar J, Granovsky S, Horak D, Kish SK (1998) Multicenter outcome study of cancer patients admitted to the intensive care unit: a probability of mortality model. J Clin Oncol 16:761–770
Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 31:1250–1256
Ascioglu S, Rex JH, de Pauw B, Bennett JE, Bille J, Crokaert F, Denning DW, Donnelly JP, Edwards JE, Erjavec Z, Fiere D, Lortholary O, Maertens J, Meis JF, Patterson TF, Ritter J, Selleslag D, Shah PM, Stevens DA, Walsh TJ (2002) Defining opportunistic invasive fungal infections in immunocompromised patients with cancer and hematopoietic stem cell transplants: an international consensus. Clin Infect Dis 34:7–14
Marshall JM, Rosenbaum PR (1999) Propensity scores. Am J Epidemiol 150:327–333
Rosenbaum PR, Rubin DB (1983) The central role of the propensity score in observational studies for causal effects. Biometrika 70:41–55
Massion PB, Dive AM, Doyen C, Bulpa P, Jamart J, Bosly A, Installe E (2002) Prognosis of hematologic malignancies does not predict intensive care unit mortality. Crit Care Med 30:2260–2270
Sculier JP, Paesmans M, Markiewicz E, Berghmans T (2000) Scoring systems in cancer patients admitted for an acute complication in a medical intensive care unit. Crit Care Med 28:2786–2792
Tsuji E, Hiki N, Nomura S, Fukushima R, Kojima J, Ogawa T, Mafune K, Mimura Y, Kaminishi M (2003) Simultaneous onset of acute inflammatory response, sepsis-like symptoms and intestinal mucosal injury after cancer chemotherapy. Int J Cancer 107:303–308
Azoulay E, Darmon M, Delclaux C, Fieux F, Bornstain C, Moreau D, Attalah H, Le Gall JR, Schlemmer B (2002) Deterioration of previous acute lung injury during neutropenia recovery. Crit Care Med 30:781–786
Alberti C, Brun-Buisson C, Burchardi H, Martin C, Goodman S, Artigas A, Sicignano A, Palazzo M, Moreno R, Boulme R, Lepage E, Le Gall R (2002) Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study. Intensive Care Med 28:108–121
Vandijck DM, Decruyenaere JM, Blot SI (2006) The value of sepsis definitions in daily ICU-practice. Acta Clin Belg 61:220–226
Chatzinikolaou I, Abi-Said D, Bodey GP, Rolston KV, Tarrand JJ, Samonis G (2000) Recent experience with Pseudomonas aeruginosa bacteremia in patients with cancer: retrospective analysis of 245 episodes. Arch Intern Med 160:501–509
Carratala J, Roson B, Fernandez-Sevilla A, Alcaide F, Gudiol F (1998) Bacteremic pneumonia in neutropenic patients with cancer: causes, empirical antibiotic therapy, and outcome. Arch Intern Med 158:868–872
Elting LS, Rubenstein EB, Rolston KV, Bodey GP (1997) Outcomes of bacteremia in patients with cancer and neutropenia: observations from two decades of epidemiological and clinical trials. Clin Infect Dis 25:247–259
Gruson D, Vargas F, Hilbert G, Bui N, Maillot T, Mayet T, Pillet O, Chene G, Gbikpi-Benissan G (2004) Predictive factors of intensive care unit admission in patients with haematological malignancies and pneumonia. Intensive Care Med 30:965–971
Herbrecht R, Denning DW, Patterson TF, Bennett JE, Greene RE, Oestmann JW, Kern WV, Marr KA, Ribaud P, Lortholary O, Sylvester R, Rubin RH, Wingard JR, Stark P, Durand C, Caillot D, Thiel E, Chandrasekar PH, Hodges MR, Schlamm HT, Troke PF, de Pauw B (2002) Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med 347:408–415
Rubin MA, Carroll KC, Cahill BC (2002) Caspofungin in combination with itraconazole for the treatment of invasive aspergillosis in humans. Clin Infect Dis 34:1160–1161
Soares M, Fontes F, Dantas J, Gadelha D, Cariello P, Nardes F, Amorim C, Toscano L, Rocco JR (2004) Performance of six severity-of-illness scores in cancer patients requiring admission to the intensive care unit: a prospective observational study. Crit Care 8:R194–R203
Benoit DD, Vandijck DM, Depuydt PO, Offner FC, Roosens CD, Noens LA, Decruyenaere JM (2006) Outcome in septic shock patients with hematological malignancies: impact of previous chemotherapy. Intensive Care Med 32 [Suppl 1]:S341, 91
Horger M, Hebart H, Einsele H, Lengerke C, Claussen CD, Vonthein R, Pfannenberg C (2005) Initial CT manifestations of invasive pulmonary aspergillosis in 45 non-HIV immunocompromised patients: association with patient outcome? Eur J Radiol 55:437–444
Heussel CP, Kauczor HU, Heussel G, Fischer B, Mildenberger P, Thelen M (1997) Early detection of pneumonia in febrile neutropenic patients: use of thin-section CT. AJR Am J Roentgenol 169:1347–1353
Acknowledgements
D.V. is financially supported by a Doctoral Grant from the Special Scientific Research Fund of the Ghent University. None of the authors have financial or other potential conflicts of interest.
Author information
Authors and Affiliations
Corresponding author
Additional information
This article is discussed in the editorial available at: http://dx.doi.org/10.1007/s00134-008-1003-1.
Rights and permissions
About this article
Cite this article
Vandijck, D.M., Benoit, D.D., Depuydt, P.O. et al. Impact of recent intravenous chemotherapy on outcome in severe sepsis and septic shock patients with hematological malignancies. Intensive Care Med 34, 847–855 (2008). https://doi.org/10.1007/s00134-008-1002-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00134-008-1002-2