Tratamiento ambulatorio del paciente con neutropenia febril / Outpatient therapy in patients with febrile neutropenia

El tratamiento de los pacientes con neoplasia y neutropenia febril plantea muchas dudas. Una de ellas, que genera ansiedad en el personal de la salud, el paciente y sus familiares, es la necesidad de hospitalización porque ésta implica exponer a gérmenes intrahospitalarios potencialmente resistentes a un paciente cuyo sistema inmune puede no estar en las mejores condiciones; incluso con un aislamiento óptimo existe el riesgo de adquirir una infección nosocomial. Muchos estudios han tratado de validar métodos para clasificar a los pacientes con fiebre y neutropenia en grupos de diferente riesgo, como fundamento para implementar estrategias de tratamiento selectivo; así se ha abierto la posibilidad de utilizar medidas más conservadoras para el tratamiento de los episodios de bajo riesgo, entre ellas la administración de regímenes orales ambulatorios de antibióticos de amplio espectro; ello sin demeritar la necesidad de aplicar un juicio clínico adecuado, hacer un buen seguimiento y tener acceso a la atención médica inmediata. La neutropenia es una de las consecuencias graves de la quimioterapia para el cáncer, y se ha demostrado que el tratamiento del paciente neutropénico febril con antibióticos intravenosos reduce la mortalidad. La terapia oral podría ser una alternativa aceptable para pacientes bien seleccionados. Ella puede mejorar la calidad de vida de los pacientes con cáncer, evitar las complicaciones asociadas con la terapia intravenosa y disminuir los costos del tratamiento.

Treatment of patients with neoplasia and febrile neutropenia, as a consequence of chemotherapy, poses many doubts, among them the need for hospitalization, since this implies exposure to potentially resistant nosocomial microorganisms. Even under the best isolation techniques, there may be risks for individuals whose immune system may not be in optimal conditions. Multiple studies have tried to validate methods for classifying patients with febrile neutropenia according to their risk of complications. Such classification systems could be the base forimplementing selective treatment strategies, one of which would be the oral ambulatory administration of wide-spectrum antibiotics. Neutropenia is one of the serious consequences of cancer chemotherapy, and it has been demonstrated that intravenous antibiotic treatment reduces mortality. Therefore,oral therapy could constitute an acceptable alternative for well-selected patients but the need for applying good clinical judgement, properly following up patients, and the availability ofimmediate access to medical attention should be emphasized. The following are among the potential benefits of oral treatment: better quality of life forpatients and their families, avoidance of the complications associated with intravenous therapy, and diminished costs of health care.

Profilaxia secundária na febre reumática. Antibioticoterapia oral versus penicilina benzatina / Secondary Prophylaxis in Rheumatic Fever Oral Antibioticotherapy versus Benzathine Penicillin

PURPOSE: To detect problems related to secondary prophylaxis of rheumatic fever in the setting out patient follow-up. METHODS: Among 113 pediatric patients admitted with diagnosis of this disease, in a period of five years, we selected 80 records. They were divided in group 1 (60 cases), that only received prescription of benzathine penicillin for prophylaxis and group 2 (20 patients) to whom it was changed from parenteral to oral antibiotics after the detection problems using the first scheme. RESULTS: In group 1, among 53 who had carditis, 27 (45) had severe disease; 22 cases (37) were re-admitted with relapsed carditis following the refusal to use benzathine penicillin. Also, we observed that after discharged 32 (55) did not return to the out-patient clinic in HUAP. In group 2, from 16 who had carditis, 10 (50) had severe disease. Only two (10) did not return to ambulatory control and there was no case of readmission. The difference between the groups was statistically significant. (p < 0.01). CONCLUSION: It was very high the percentage of cases that missed the control visits and abandoned the prophylaxis when it was insisted on parenteral penicillin. We should evaluate every case and remember that oral antibiotics might avoid a major problem.

Objetivo - Detectar problemas ligados à profilaxia secundária na febre reumática, através do seguimento ambulatorial dos pacientes. Métodos - Dentre 113 pacientes pediátricos internados, num período de cinco anos, com diagnóstico da doença, selecionamos 80 casos confirmados, divididos em grupo 1 (60 casos) - crianças que só receberam penicilina benzatina para profilaxia secundária e grupo 2 (20 pacientes) - onde a penicilina benzatina foi substituída por antibioticoterapia oral, ao se detectar problemas com o primeiro esquema. Resultados - No grupo 1, dos 53 que tiveram cardite, 27 (45%) eram graves. Em 22 (37%) ocorreram reinternações por recaída e destes, 12 (55%) porque o paciente recusou a penicilina benzatina. Observamos também que, após a alta hospitalar, 32 (55%) não retornaram para cotrole ambulatorial no HUAP. No grupo 2, dos 16 que tiveram cardite, 10 (50%) eram graves. Não ocorreu nenhum caso de abandono da profilaxia e apenas dois (10%) não retornaram para controle ambulatorial. Comparando a taxa de faltosos e de abandono da medicação, nos dois grupos, a diferença foi significativa para as duas variáveis. (p<0,01). Conclusão - Foi muito elevada a porcentagem de faltosos e de reinternação por abandono da medicação, no grupo da profilaxia parenteral. Deve-se avaliar cada caso e lembrar que a medicação oral pode evitar uma perda maior