Abstract
Empirical antibiotics at the onset of febrile neutropenia are one of several strategies for management of bacterial infections in patients undergoing Hematopoietic Stem Cell Transplant (HSCT) (empiric strategy). Our HSCT program aims to perform HSCT in an outpatient setting, where an empiric antibiotic strategy was employed. HSCT recipients began receiving intravenous antibiotics at the onset of neutropenia in the absence of fever as part of our institutional policy from 01 Jan 2009; intravenous Prophylactic strategy. A prospective study was conducted to compare two consecutive cohorts [Year 2008 (Empiric strategy) vs. Year 2009 (Prophylactic strategy)] of patients receiving HSCT. There were 238 HSCTs performed between 01 Jan 2008 and 31 Dec 2009 with 127 and 111 in the earlier and later cohorts respectively. Infection-related mortality pre- engraftment was similar with a prophylactic compared to an empiric strategy (3.6% vs. 7.1%; p = 0.24), but reduced among recipients of autologous HSCT (0% vs. 6.8%; p = 0.03). Microbiologically documented, blood stream infections and clinically documented infections pre-engraftment were reduced in those receiving a prophylactic compared to an empiric strategy, (11.7% vs. 28.3%; p = 0.001), (9.9% vs. 24.4%; p = 0.003) and (18.2% vs. 33.9% p = 0.007) respectively. The prophylactic use of intravenous once-daily ceftriaxone in patients receiving outpatient based HSCT is safe and may be particularly effective in patients receiving autologous HSCT. Further studies are warranted to study the impact of this Prophylactic strategy in an outpatient based HSCT program.
Highlights
Bacteria are the major causative organisms of infections in the engraftment phase following hematopoietic stem cell transplant (HSCT)
There were 238 Hematopoietic Stem Cell Transplant (HSCT) performed at the Ottawa Hospital Blood and Marrow Programme between Jan 2008 to Dec 2009
All but 2 deaths prior to engraftment in the prophylactic strategy group were attributable to infections, and no patients were lost to follow-up
Summary
Bacteria are the major causative organisms of infections in the engraftment phase following hematopoietic stem cell transplant (HSCT). The use of peripheral blood stem cells and growth factors (G-CSF) shortens this phase, potentially improving infectious outcomes [1]. Neutropenic fevers occur in 90% and 80% of patients following allogeneic and autologous transplants respectively and [2,3,4,5] bacterial infections remain a leading cause of morbidity and mortality in HSCT recipients [6,7,8]. An empiric strategy may be suboptimal as life-threatening septicemia may precede the development of fevers. This possibility becomes more worrisome when HSCT is performed in the outpatient setting. A pre-emptive strategy has been proposed [14] to optimize the benefits antibiotic use while limiting its complications
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