Aztreonam and Vancomycin Use for Episodes of Febrile Neutropenia During Hematopoetic Stem Cell Transplantation

Abstract

The spectrum of bacterial infections seen during febrile neutropenia(FN) in HSCT recipients continues to change, especially with the emergence of multi-drug resistant organisms. Aztreonam(AZ) plus Vancomycin (VAN) have been used successfully for FN in cancer patients, however the effectiveness of AZ plus VAN for FN during HSCT is largely unknown. A retrospective chart review was performed to determine the effectiveness of AZ in FN. 822 consecutive HSCT patient charts were reviewed(2004-2008). All patients received a minimum of 48hours of AZ/VAN treatment for FN. Patients had received ciprofloxacin as prophylaxis. The criteria for success was based upon evidence based guidelines for the evaluation of new anti-infective drugs in FN FN(CID Vol.15 Nov 1992 Suppl: 206-15) as follows:1.Unexplained fever: defervesence within 72hr without recurrence and no clinical s/s infection.2.Clinically defined infection: Clinical improvement including fever, without antibiotic change or death3.Microbiologically defined infection: All s/s and microbiological evidence of disease eradicated without recurrence for 7days. 67 AZ treated patients were identified. Demographics: age = 59(24-77), gender male = 29, Diagnosis: myeloma = 48, NHL = 10, AML = 7, HSCT type: autologous = 45. allogeneic = 22. Median time to start AZ(post-HSCT infusion): day +8(-6-12), Number of AZ treatment days = 6(2-33) Treatment Outcome1.Unexplained fever(n = 36): Success = 26/36(73%), 2 patients died2.Clinically defined(n = 12): Hospital Pneumonia(n = 9): Success = 5/9(55%-ATB changes), Typhlitis (n = 1) 0/1 (ATB change), Cellulitis(n = 1)(0/1success (ATB change)3.Microbiologically defined infection (see Table 1): 20 patients experienced 30 episodes of microbiologically confirmed infection. The majority (80%) were gram positive cocci blood stream infections and were successfully treated (80%-2 died). Gram negative BS infection overall success was 50%(1died) 6 patients developed clinical CDAD and 9 patients became VRE surveillance positive shortly after AZ treatment. A non-significant trend towards more BS infections was seen in allo-HSCT recipients(p = 0.086) AZ/VAN was effective in preventing breakthrough infections for patients with unexplained fever, but less effective for patients with documented infections, requiring change or addition of antibiotics. These results are comparable to those seen in non-HSCT cancer patients with FN(Bodey et al.Cancer 1996 Apr1 77(7)).Table 1Microbiologically Defined InfectionOrganismSourceSuccessful Outcome(%)Strept Viridansblood (n = 11)91 (1 died-polymicrobial)CONS(2 positive cx's at 2sitesblood (n = 5)80 (changed atb)Entereococcus Faecalisblood (n = 4)75 (1died-polymicrobial)MSSAblood (n = 2)50 (1 died-polymicrobialE.Coliblood = 1/urine = 1BS-1 died//Urine = successEnterobacterurine (n = 1)100Burkholderiablood = 10 ( died-polymicrobial)C.Diffstool (n = 3)66 (1 died-polymicrobial) Open table in a new tab