Cessation of Ciprofloxacin Prophylaxis in Hemato-Oncology Patients

Caldwell, Louise; Bapat, Anjaneya; Drumright, Lydia N; Lambourne, Jonathon; Jimenez-England, Fergus; Aries, James; Eccersley, Lydia; Hallam, Simon; Montoto, Silvia; Oakervee, Heather; Riches, John C.; Agrawal, Samir

doi:10.1093/cid/ciab1000

Cited by 13 publications

(5 citation statements)

References 7 publications

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“…Other studies in the adult hematology or HSCT cohort have also observed reductions in fluoroquinoloneresistant and MDRO BSIs following the discontinuation of routine fluoroquinolone prophylaxis without changes in mortality. 86,87 One of these studies was followed up with a subsequent 9-year follow-up that supported the original findings. 88 Among the pediatric cohort, the impact of fluoroquinolone prophylaxis on AMR is less clear, as well-conducted studies are limited.…”

Section: Impact On Antimicrobial Resistant Infectionsmentioning

confidence: 66%

“…Further, although per‐episode BSI mortality was higher in fluoroquinolone recipients, overall mortality was not significantly different, partly because the absolute BSI risk was lower. Other studies in the adult hematology or HSCT cohort have also observed reductions in fluoroquinolone‐resistant and MDRO BSIs following the discontinuation of routine fluoroquinolone prophylaxis without changes in mortality 86,87 . One of these studies was followed up with a subsequent 9‐year follow‐up that supported the original findings 88 …”

Section: Introductionmentioning

confidence: 64%

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Fluoroquinolone prophylaxis in patients with neutropenia at high risk of serious infections: Exploring pros and cons

Singh,

Thursky,

Maron

et al. 2023

Transplant Infectious Dis

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BackgroundThe use of fluoroquinolones to prevent infections in neutropenic patients with cancer or undergoing hematopoietic stem cell transplantation (HSCT) is a controversial issue, with international guidelines providing conflicting recommendations. Although potential benefits are clear, concerns revolve around efficacy, potential harms, and antimicrobial resistance (AMR) implications.DiscussionFluoroquinolone prophylaxis reduces neutropenic fever (NF) bloodstream infections and other serious bacterial infections, based on evidence from systematic reviews, randomized controlled trials, and observational studies in adults and children. Fluoroquinolone prophylaxis may also reduce infection‐related morbidity and healthcare costs; however, evidence is conflicting. Adverse effects of fluoroquinolones are well recognized in the general population; however, studies in the cancer cohort where it is used for a defined period of neutropenia have not reflected this. The largest concern for routine use of fluoroquinolone prophylaxis remains AMR, as many, but not all, observational studies have found that fluoroquinolone prophylaxis might increase the risk of AMR, and some studies have suggested negative impacts on patient outcomes as a result.ConclusionsThe debate surrounding fluoroquinolone prophylaxis calls for individualized risk assessment based on patient characteristics and local AMR patterns, and prophylaxis should be restricted to patients at the highest risk of serious infection during the highest risk periods to ensure that the risk‐benefit analysis is in favor of individual and community benefit. More research is needed to address important unanswered questions about fluoroquinolone prophylaxis in neutropenic patients with cancer or receiving HSCT.

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Section: Impact On Antimicrobial Resistant Infectionsmentioning

confidence: 66%

Section: Introductionmentioning

confidence: 64%

Fluoroquinolone prophylaxis in patients with neutropenia at high risk of serious infections: Exploring pros and cons

Singh,

Thursky,

Maron

et al. 2023

Transplant Infectious Dis

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“…The results reported reductions in fever episodes but not mortality [ 18 , 19 ]. Caldwell et al suggest that discarding FQP might result in increased febrile episodes but later in decreased resistant isolates, along with no increase in mortality or ICU admission [ 32 ].…”

Section: Discussionmentioning

confidence: 99%

Cost-Effectiveness of Targeted Prophylaxis among Allogenic Stem Cell Transplant Recipients

Shbaklo

Vicentini

Busca³

et al. 2023

Pharmaceuticals

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Bloodstream infections (BSI) are life-threatening complications for onco-hematologic patients. Fluoroquinolones prophylaxis (FQP) was recommended for patients with neutropenia. Later, it was correlated with increased resistance rates among this population and its role became debated. While the role of FQ prophylaxis is still being studied, its cost-effectiveness is also unknown. The objective of this study was to evaluate the costs and effects associated with two alternative strategies (FQP vs. no prophylaxis) for patients with hematological malignancies undergoing allogenic stem cell transplant (HSCT). A decision-tree model was built integrating retrospectively collected data from a single transplant center, part of a tertiary teaching hospital in Northern Italy. Probabilities, costs and effects were considered in the assessment of the two alternative strategies. Probabilities of colonization, BSIs, extended-spectrum beta lactamase (ESBL) and Klebsiella pneumoniae carbapenemase (KPC) BSIs and mortality associated with infection, as well as median duration of length of stay (LOS) were calculated based on data collected between 2013 and 2021. The center applied the strategy of FQP between 2013 and 2016, and of no prophylaxis between 2016 and 2021. Data on 326 patients were collected during the considered time period. Overall, the rates of colonization, BSI, KPC/ESBL BSI, and mortality were 6.8% (95% confidence interval (CI) 2.7–13.5), 42% (9.9–81.4) and 20.72 (16.67–25.26), respectively. A mean bed-day cost of 132€ was estimated. Considering no prophylaxis vs. prophylaxis, the difference in costs ranged between additional 33.61 and 80.59€ per patient, whereas the difference in effects ranged between 0.11 and 0.03 life-years (LYs) lost (around 40 and 11 days). Given the small differences in terms of costs and effects between the two strategies, no prophylaxis seems an appropriate choice. Furthermore, this analysis did not consider the broader effect on hospital ecology of multiple doses of FQP, which could provide further support for the strategy of no prophylaxis. Our results suggest that the necessity for FQP in onco-hematologic setting should be determined based on local antibiotic resistance patterns.

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“…While there is more comfort with the use of FQs in pediatrics, long-term impacts on antibiotic resistance in pediatric populations are unknown [ 15 , 16 ]. However, increased incidence and duration of FQ therapy is associated with the emergence of FQ-resistant pathogens, and there is conflicting evidence linking it to the emergence of MDR organisms [ 6 , 17 ]. Based on our results, the epidemiology of inpatient FQ receipt has shifted among high-risk patient groups between 2015 and 2020 with clear trends via both changes in proportional use and use per encounter for the identified patient groups.…”

Section: Discussionmentioning

confidence: 99%

“…However, while associated with fewer febrile episodes and bacterial infections when compared to no prophylaxis, there was no significant difference in these outcomes when compared to any other prophylaxis regimens [ 23 , 24 ]. Additionally, recent studies have found increased incidence of MDR and FQ-resistant infections associated with their use, with resultant ineffective prophylaxis in some patients [ 17 , 25 ]. Tracking FQ use in oncology patients and other medically complex children is important, as the emergence and transmission of FQ-resistant infections contributes to the burden of antimicrobial resistance hospital-wide and in the community [ 26 ].…”

Section: Discussionmentioning

confidence: 99%

Fluoroquinolone Use Among Hospitalized Children: Diagnosis-Based Stratification to Identify Stewardship Targets

Parzen-Johnson

Sun

Scardina

et al. 2023

Open Forum Infectious Diseases

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Background As FQ (fluoroquinolone) use has shifted in pediatric populations, better metrics are needed to guide targeted antibiotic stewardship interventions and limit development of adverse events and resistance, particularly in medically complex children. In this study, we identify high-utilization groups based on underlying medical conditions and describe their relative FQ use over time. Methods This study is a retrospective analysis of data from the Pediatric Health Information System (PHIS) database from 2016-2020. We identify high-utilization groups based on underlying medical conditions using ICD-9/10 codes. We delineate overall trends in the use of FQs in the inpatient setting, including rate and proportional use by each patient group. Results Patients with an oncology diagnosis represent a large (25-44%) and rising proportion (+4.8%/yr, p = 0.001) of national FQ use over the study period. Patients with intraabdominal infections, including appendicitis, have had a significant increase in both their relative proportional use of FQ (+0.6%/yr, p = 0.037) and proportion of FQ use per admission encounter over the study period (+0.6%/yr, p = 0.008). Patients with cystic fibrosis (CF) represent a decreasing proportion of overall use (-2.1%/yr, p = 0.011) and have decreasing FQ use per inpatient encounter (-0.8%/yr, p = 0.001). Conclusions Patients with an oncology diagnosis and patients with an intraabdominal infection appear to be targets for FQ stewardship. Patients with CF have decreasing inpatient FQ use.

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Cessation of Ciprofloxacin Prophylaxis in Hemato-Oncology Patients

Cited by 13 publications

References 7 publications

Fluoroquinolone prophylaxis in patients with neutropenia at high risk of serious infections: Exploring pros and cons

Fluoroquinolone prophylaxis in patients with neutropenia at high risk of serious infections: Exploring pros and cons

Cost-Effectiveness of Targeted Prophylaxis among Allogenic Stem Cell Transplant Recipients

Fluoroquinolone Use Among Hospitalized Children: Diagnosis-Based Stratification to Identify Stewardship Targets

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