Abstract
BackgroundRising antibiotic resistance poses a challenge to the management of febrile neutropenia in patients with haematological malignancies receiving chemotherapy.AimWe studied an alternating first-line antibiotic strategy to determine its impact on all-cause mortality and bacteremia rates in patients with febrile neutropenia.MethodsAn alternating first-line antibiotic strategy was established in mid-2013. Data for 2012 (before strategy implementation) and 2014 (post-strategy implementation) were compared. Antibiotic Heterogeneity Index (AHI) for each of the two time-periods was also calculated.FindingsThere were 2012 admissions (26082 patient-days) in 2012 and 1843 admissions (24331 patient-days) in 2014. There was no significant difference in the baseline characteristics of patients in the two groups. The defined daily doses (DDD) of cefepime (CEF) fell while the DDD of piperacillin-tazobactam (PTZ) rose in 2014 compared with 2012. Vancomycin DDD fell in 2014. The AHI was 0.466 in 2012 and 0.582 in 2014. The difference in all-cause mortality was not statistically significant. There was no difference in rates of bacteremia with CEF-resistant, PTZ-resistant and carbapenem-resistant gram-negative organisms in the two groups. Rates of new cases of Methicillin-resistant Staphylococcus aureus (MRSA) were 2.38/1000 and 2.59/1000 patient-days in 2012 and 2014 respectively. Rates of new cases of Vancomycin-resistant Enterococcus (VRE) were 1.84/1000 and 1.81/1000 patient-days in 2012 and 2014 respectively. There was no Carbapenem-resistant Enterobacteriaceae (CRE) bacteremia in 2012 and 1 in 2014.ConclusionAn alternating first-line antibiotic strategy resulted in an increase in antibiotic heterogeneity, without increasing mortality. There was also no significant increase in bacteremia rates.
Highlights
Empirical antibiotics are crucial in the management of fever in patients who are neutropenic after chemotherapy for haematological malignancies. [1]Rising antibiotic resistance, threatens to limit the options for empirical and definitive treatment
An alternating first-line antibiotic strategy resulted in an increase in antibiotic heterogeneity, without increasing mortality
In view of data negative for cycling and promising for antibiotic heterogeneity, increasing antibiotic heterogeneity was considered a viable approach to the rising problem of multi-drug resistant organisms (MDROs)
Summary
Empirical antibiotics are crucial in the management of fever in patients who are neutropenic after chemotherapy for haematological malignancies. [1]Rising antibiotic resistance, threatens to limit the options for empirical and definitive treatment. Empirical antibiotics are crucial in the management of fever in patients who are neutropenic after chemotherapy for haematological malignancies. Infections with multi-drug resistant organisms (MDROs) carry a high mortality, especially in the haematology-oncology setting. [6] Like other haematology units, we were concerned about the increase in multi-, extremely- and pan-drug resistant (M-, X-, P-DR) gram-negatives, and their adverse impact on patient survival.[2, 3, 7,8,9]. Heavy use of an antibiotic over a prolonged period will likely engender resistance to that antibiotic. [10, 11] As this alternative has not been used in the previous period, most of the organisms in the unit should be susceptible to it. Rising antibiotic resistance poses a challenge to the management of febrile neutropenia in patients with haematological malignancies receiving chemotherapy.
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