Empirical antibiotics targeting gram-positive bacteria for the treatment of febrile neutropenic patients with cancer

Beyar-Katz, Ofrat; Dickstein, Yaakov; Borok, Sara; Vidal, Liat; Leibovici, Leonard

doi:10.1002/14651858.cd003914.pub4

Cited by 32 publications

(16 citation statements)

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“…In alignment with epidemiologic changes showing an increase in infection by Gram-positive organisms, anti-Gram-positive antibiotics (usually vancomycin) have been incorporated in the empirical regimen (7)(8)(9). However, a meta-analysis of randomized trials comparing regimens with or without vancomycin failed to show an advantage of vancomycin in the initial empirical regimen (10,11). Indeed, practical guidelines for the management of febrile neutropenia do not recommend its routine use in the empirical antibiotic regimen, except in certain circumstances, such as suspected catheter-related infection, skin and soft tissue infection, pneumonia, or hemodynamic instability (12,13).…”

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confidence: 99%

Shock and Early Death in Hematologic Patients with Febrile Neutropenia

Guarana

Nucci

Nouér

2019

Antimicrob Agents Chemother

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Empirical antibiotic therapy with a beta-lactam is the standard of care in febrile neutropenia (FN) and is given to prevent early death. The addition of vancomycin is recommended in certain circumstances, but the quality of evidence is low, reflecting the lack of clinical data. In order to characterize the epidemiology of early death and shock in FN, we reviewed all episodes of FN from 2003 to 2017 at University Hospital, Federal University of Rio de Janeiro, and looked at factors associated with shock at first fever and early death (within 3 days from first fever) by univariate and multivariate analyses. Among 1,305 episodes of FN, shock occurred in 42 episodes (3.2%) and early death in 15 (1.1%). Predictors of shock were bacteremia due to Escherichia coli (odds ratio [OR], 8.47; 95% confidence interval [95% CI], 4.08 to 17.55; P < 0.001), Enterobacter sp. (OR, 7.53; 95% CI, 1.60 to 35.33; P = 0.01), and Acinetobacter sp. (OR, 6.95; 95% CI, 1.49 to 32.36; P = 0.01). Factors associated with early death were non-Hodgkin’s lymphoma (OR, 3.57; 95% CI, 1.18 to 10.73; P = 0.02), pneumonia (OR, 21.36; 95% CI, 5.72 to 79.72; P < 0.001), shock (OR, 11.64: 95% CI, 2.77 to 48.86; P = 0.01), and bacteremia due to Klebsiella pneumoniae (OR, 5.91; 95% CI, 1.11 to 31.47; P = 0.03). Adequate empirical antibiotic therapy was protective (OR, 0.23; 95% CI, 0.07 to 0.81; P = 0.02). Shock or early death was not associated with Gram-positive bacteremia; catheter-related, skin, or soft tissue infection; or inadequate Gram-positive coverage. These data challenge guideline recommendations for the empirical use of vancomycin at first fever in neutropenic patients.

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confidence: 99%

Shock and Early Death in Hematologic Patients with Febrile Neutropenia

Guarana

Nucci

Nouér

2019

Antimicrob Agents Chemother

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“…Overuse of vancomycin is associated with future development of vancomycin-resistant Enterococcus sp and Staphylococcus sp. Furthermore, receipt of vancomycin in patients with NF does not decrease the time to defervescence (Paesmans et al, 2011) or all-cause mortality (Beyar-Katz et al, 2017).…”

Section: Discussionmentioning

confidence: 99%

“…The addition of empirical vancomycin should be reserved for patients with severe CVC-associated infections (e.g., chills and rigors with infusion through catheter, etc. ), skin and soft tissue infections (SSTIs), pneumonia, volatile hemodynamics, severe mucositis with a history of FQ prophylaxis and empirical ceftazidime, or documented recent or current Gram-positive infection, as routine use does not decrease mortality (Freifeld et al, 2011;Freifeld and Razonable, 2014;Beyar-Katz et al, 2017;Wright et al, 2013). Furthermore, widespread deployment of vancomycin empirically promotes resistance in Enterococcus sp and Staphylococcus sp, with increased potential for adverse events (Freifeld et al, 2011).…”

Section: Introductionmentioning

confidence: 99%

Evaluating guideline adherence regarding empirical vancomycin use in patients with neutropenic fever

Chastain

Wheeler

Franco‐Paredes

et al. 2018

International Journal of Infectious Diseases

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“…According to the guideline recommendation, addition of Gram-positive antibiotic coverage to the initial empiric antibiotic regimen has not been associated with significant clinical benefit. [ 1 14 15 16 ] A meta-analysis of 14 randomized trials found that addition of Gram-positive antibiotic coverage to standard empiric therapy did not reduce all-cause mortality in patients with cancer and neutropenic fever. [ 14 ] However, in our study, vancomycin was added to near 50% of initial empiric antibiotic regimen because most of our practitioners had fear of upcoming hemodynamic instability.…”

Section: Discussionmentioning

confidence: 99%

Management of febrile neutropenia: A description of clinical and microbiological findings by focusing on risk factors and pitfalls

et al. 2018

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Objective:Febrile neutropenia (FN) is one of the most serious clinical problems in patients with hematologic malignancies and patients receiving chemotherapy. The present study was implemented to determine precisely how FN is managed in most referral hospitals in Isfahan (Iran) and what are the characteristics of FN patients as well as risk factors associated with FN development.Methods:This study was a cross-sectional study performed over a period of 6 months on patients hospitalized in the Hematology-Oncology Center of Omid Hospital, Isfahan, Iran. The information was collected by filling the designed data abstraction form.Findings:A total of 115 oncology patients were admitted with or encountered to FN. This equates to a cumulative incidence of 1.26% of FN cases per 1000 oncology admissions. The average age was 49.5 ± 18.02 years (range 18–85 years), with 42.6% of patients being female. The most frequently prescribed antibiotic agents were meropenem (91.3%) and vancomycin (47.82%) alone or in combination. Empiric antifungal agents initiated in 20.86% of cases, and we could not find any patients who needed to receive antiviral treatment. From all positive cultures, Gram-positive microorganisms were the most found pathogen. Among them, female sex (42.6%) and lymphopenia (26.5%) were the most noted predictors. Neutropenia (81.7%) was the most reported risk factors for serious complications.Conclusion:Although our center is university-affiliated, there are still several points, and pitfalls must be considered and revised in the management of FN patients. Obtaining and assessing the samples microbiologically and antibiotic therapy accordingly were the most troublesome complications.

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Empirical antibiotics targeting gram-positive bacteria for the treatment of febrile neutropenic patients with cancer

Abstract: Based on very low- or low-quality evidence using the GRADE approach and overall low risk of bias, the current evidence shows that the empirical routine addition of antiGP treatment, namely glycopeptides, does not improve the outcomes of febrile neutropenic patients with cancer.

Cited by 32 publications

References 71 publications

Shock and Early Death in Hematologic Patients with Febrile Neutropenia

Shock and Early Death in Hematologic Patients with Febrile Neutropenia

Evaluating guideline adherence regarding empirical vancomycin use in patients with neutropenic fever

Management of febrile neutropenia: A description of clinical and microbiological findings by focusing on risk factors and pitfalls

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