Impact of Prophylactic Levofloxacin on Rates of Bloodstream Infection and Fever in Neutropenic Patients with Multiple Myeloma Undergoing Autologous Hematopoietic Stem Cell Transplantation

Abstract

Few studies have evaluated the role of antibacterial prophylaxis during neutropenia in patients with multiple myeloma undergoing autologous hematopoietic stem cell transplantation (HSCT). At our center, levofloxacin prophylaxis was initiated in June 2006 in patients with myeloma who were undergoing autologous HSCT. We compared the incidence of bloodstream infection (BSI) and fever and neutropenia (FN) within 30 days of transplantation before (January 2003 - May 2006) and after (June 2006 - April 2010) the initiation of levofloxacin prophylaxis in patients undergoing autologous HSCT for myeloma. We also compared rates of BSI and FN during the same time periods in autologous HSCT recipients with lymphoma who did not receive antibacterial prophylaxis during either time period. After the initiation of levofloxacin prophylaxis, the BSI rate decreased from 41.2% (49/119) to 14.7% (23/156) and the rate of FN decreased from 91.6% to 60.9% in patients with myeloma (P < 0.001, for each). In contrast, rates of BSI (43.1% vs. 47.3%; P = 0.50) and FN (98.8% vs. 97.1%; P = 0.63) did not change in patients with lymphoma. Levofloxacin prophylaxis was independently associated with decreased odds of BSI (odds ratio [OR] 0.27; 95% confidence interval [CI] 0.14–0.51; P < 0.001) and FN (OR 0.18, 95% CI 0.09–0.36; P < 0.001) in multivariate analysis. Patients with myeloma had a non-significant increase in the risk of BSI due to levofloxacin-resistant Enterobacteriaceae (5% vs. 1%, P = 0.08) and Clostridium difficile infection (7% vs. 3%, P = 0.12) after the initiation of levofloxacin prophylaxis, but did not have higher rates of BSI due to other resistant bacteria. Levofloxacin prophylaxis is associated with decreased risk of BSI and FN in patients with myeloma undergoing autologous HSCT.

Bacterial bloodstream infections in the allogeneic hematopoietic cell transplant patient: new considerations for a persistent nemesis

“…However, they also demonstrated a non-significant increase in Clostridium difficile and fluoroquinolone-resistant Enterobacteriaceae infections. 98 Finally, levofloxacin prophylaxis was not associated with decreased BSI rates complicated by severe sepsis or ICU admission. 98 It is important to note that any benefit for fluoroquinolone prophylaxis could potentially be offset by increased rates of emerging resistant pathogens.…”

“…98 Finally, levofloxacin prophylaxis was not associated with decreased BSI rates complicated by severe sepsis or ICU admission. 98 It is important to note that any benefit for fluoroquinolone prophylaxis could potentially be offset by increased rates of emerging resistant pathogens. 99,100 The proportion of BSIs caused by fluoroquinolone-resistant bacteria has increased (Tables 1 and 2), likely secondary to the use of fluoroquinolone prophylaxis.…”

“…97 In addition, prophylaxis may have increased MDR bacterial strains. 97 Satlin et al 98 reported 27% absolute reduction in BSI and 31% absolute reduction in febrile neutropenia episodes within 30 days after HCT in patients receiving levofloxacin prophylaxis. However, they also demonstrated a non-significant increase in Clostridium difficile and fluoroquinolone-resistant Enterobacteriaceae infections.…”

Antimicrobial Resistance in Gram-Negative Rods Causing Bacteremia in Hematopoietic Stem Cell Transplant Recipients: Intercontinental Prospective Study of the Infectious Diseases Working Party of the European Bone Marrow Transplantation Group

“…Information about resistance rates and risk factors in auto-HSCT patients i and mainly concerns fluoroquinolones [15,30], as bacteremia is relatively le frequent in auto-HSCT patients [31]. Certain factors predisposing to resista infections-such as breakthrough bacteremia and prolonged neutropeniafrequent in auto-HSCT vs allo-HSCT patients (Table 2).…”

Italian consensus conference for the outpatient autologous stem cell transplantation management in multiple myeloma

“…A recent study suggests that Levofloxacin prophylaxis is associated with decreased risk of bloodstream infection and fever in patients with myeloma undergoing ASCT. 59 Primary antifungal prophylaxis is not recommended in the ASCT setting. 60,61 However, in the case of symptomatic mucositis, oral fluconazole at 200-400 mg/day should be started until complete hematological recovery.…”