Empirical therapy of febrile neutropenic patients with mucositis: challenge of risk-based therapy

Nowadays Gram-positive cocci, especially oral viridans streptococci (OVS) a nd coagulase-negative staphylococci (CoNS), are the most common bloodstream isolates in febrile neutropenic patients, Although in general these cocci are quite indolent, Streptococcus mitis is associated with serious complica tions such as sepsis and/or adult respiratory distress syndrome. Neutropeni a is the most significant predisposing factor but the impact of mucositis, i.e. damage to the mucosal barrier of mouth and intestines (mucosal barrier injury, MBI), is very much greatly underestimated. Oral mucositis is a str ong predictor of OVS bacteremia and simultaneously CoNS bacteremia is clear ly associated with mucositis. Treatment with especially high dose cytarabin e, cyclophosphamide and idarubicin, when given to allogeneic hematopoietic stem cell transplant recipients, predictably results in mucositis. Hence, t he occurrence of mucositis should have implications for complementing empir ical therapy with specific drugs such as glycopeptides, because risk patien ts can be selected based upon the chemotherapeutic therapy administered. An algorithm is presented for dealing with patients at high risk of mucositis and bacteremia due to Gram-positive cocci.