Hematolojik Maligniteli Hastalarda İnvaziv Küf Enfeksiyonları: Çevresel Faktörlerin Etkisi

Invasive Mold Infections in Patients with HematologicMalignities: The Effects of Environmental Factors

Engin KELKİTLİ, Asuman BİRİNCİ, Tuba KURUOĞLU, Fatih TEMOÇİN, Aynur ATİLLA, Merve ÇELİK, Özkul Yılmaz ÇOLAK

Özet

nvaziv mantar enfeksiyonları (İME), hematolojik malignitesi olan hastalarda önemli bir morbidite ve mortalite nedeni olmaya devam etmektedir. Bu hastalardaki İME’nin çoğunu Candida ve Aspergillus türleri oluşturmaktadır. İnvaziv aspergilloz epidemilerinin çoğunun hastanedeki inşaat çalışmaları ile ilgili olduğu bildirilmiştir. Bu çalışmada, hematolojik maligniteli hastalarda eski hastane binasında ve taşınma sonrası yeni hastane binasındaki İME sıklığının araştırılması amaçlanmıştır. Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Hematoloji Kliniğinde Ocak 2015-Eylül 2019 tarihleri arasında yatarak takip edilen 8042 hastadan antifungal tedavi başlanan 412 hasta çalışmaya dahil edilmiştir. Ocak 2018 tarihinde yeni onkoloji hastane binasına taşınan Hematoloji Kliniğindeki hastalar taşınma öncesi ve taşınma sonrası olarak gruplandırılarak demografik verileri, hematolojik tanı, uygulanan kemoterapi, mortalite, İME, enfeksiyon odağı, santral venöz kateter varlığı, antifungal proflaksi ve tedavi, galaktomannan düzeyi, mantar kültürü, bilgisayarlı tomografi (BT) bulguları retrospektif olarak değerlendirilmiştir. Hastaların %55’i erkek, medyan yaş 58 yıl (yaş aralığı= 18- 93 yıl) olarak tespit edilmiştir. İnvaziv mantar enfeksiyonu gelişme oranı %5.12 (n= 412), invaziv küf enfeksiyonu gelişme oranı ise %1.2 (n= 145) bulunmuştur. En sık antifungal tedavi başlanan hematolojik hastalık %50 (n= 206/412) oranı ile akut miyeloid lösemi (AML) olarak saptanmıştır. Hastaların %73’ü indüksiyon kemoterapisi (birinci indüksiyon %42, reindüksiyon %31), %13.4’ü konsolidasyon tedavisi almıştır. İnvaziv küf enfeksiyon tanısı; %40 muhtemel (possible), %59 yüksek olasılıklı (probable), %1 kanıtlanmış (proven) şeklinde konulmuştur. Hastaların taşınma öncesi ve sonrası yaş, cinsiyet, hematolojik hastalık, uygulanan kemoterapi, antifungal profilaksi gibi özellikleri benzerken invaziv küf enfeksiyonu gelişme oranı taşınma öncesi %2.1, 1000 hasta gününde 2.06, taşınma sonrası %1.37 (p= 0.009), 1000 hasta gününde 1.15 (p

Abstract

Invasive fungal infections (IFI) continue to be an important cause of morbidity and mortality in patients with hematological malignancies. Candida and Aspergillus species constitute most of the IFI in these patients.. It has been reported that most of the invasive aspergillosis epidemics are related to the construction works in the hospital. In this study, we aimed to investigate the frequency of IFI in the old and the new hospital building after relocation in patients with hematological malignancies. Of 8042 patients who were hospitalized in the Department of Hematology, Ondokuz Mayıs University Faculty of Medicine between January 2015 and September 2019, 412 patients who were initiated antifungal therapy were included in the study. The patients in the hematology clinic, which were moved to the new oncology hospital building in January 2018, were grouped as prior and after relocation, and their demographical data, hematological diagnosis, chemotherapy regimens, mortality, IFI, focus of infection, presence of central venous catheter, antifungal prophylaxis and treatment, galactomannan level, fungal culture and computed tomography (CT) findings were evaluated retrospectively. It was determined that 55% of the patients were male and the median age was 58 (range:18-93). The rate of IFI development was 5.12% (n= 412) and the rate of invasive mold infection was 1.2% (n= 145). The most common hematological disease for which antifungal treatment initiated was acute myeloid leukemia (AML) with a rate of 50% (n= 206/412). Of patients, 73% received induction chemotherapy (42%, first induction, 31% reinduction), 13.4% received consolidation therapy. Invasive mold infection was diagnosed as 40% possible, 59% probable, 1% proven. While patients had similar characteristics such as age, gender, hematological disease, chemotherapy regimens and antifungal prophylaxis prior and after transportation, the rate of development of invasive mold infection was 2.1%, 2.06 / 1000 patient days, before transportation, 1.37% (p= 0.009), 1.15/1000 patient days (p< 0.001) after transportation, and it was statistically significantly lower after transportation. The median value of galactomannan antigen was detected as 0.17 (0.02-5.9). Blood cultures revealed 10.3% fungal growth and the most common growth was Candida albicans with 54.8% and Mucor spp. as mold with 3.2%. Large-scale construction works such as renovation, extension and demolition works in old hospital buildings are a permanent condition in different units. Clinicians should be aware of that infections due to opportunistic fungi can be seen in immunosuppressive patients close to such construction sites, and even cause epidemics. It should be kept in mind that these infections, which can progress with serious morbidity and mortality are difficult to treat but can be prevented by infection control measures.