Incomplete recovery of the fecal flora of hematological patients with neutropenia and repeated fluoroquinolone prophylaxis

Abstract

BackgroundRoutine fluoroquinolone prophylaxis in neutropenic patients with hematological malignancies is still controversial, because of antibiotic resistance concerns. The recovery of the fecal microbiota to the initial composition in patients receiving multiple courses of quinolone prophylaxis and repeated chemotherapy has not been evaluated.MethodsWe prospectively examined the changes in the fecal bacterial composition before and after levofloxacin prophylaxis. A sequential observation of bacterial resistance in patients receiving multiple prophylactic courses was also conducted.ResultsIn this trial, 68 cases, including (35 with the first course and 33 with the second and subsequent courses) were registered. The disappearance of quinolone-susceptible (QS) Entero-bacteriaceae and dominant emergence of quinolone-resistant (QR) coagulase negative staphylococci (CNS) and QR Enterococci were observed after the first prophylaxis. The detection of QS Enterobacteriaceae was recovered before the second and subsequent courses to a level of the initial composition (28/35 samples, 80.0% before the first course vs 23/33 samples, 69.7% before the second and subsequent courses, P=0.41). In contrast, the detection rate of QR CNS and Enterococci significantly increased at the second and subsequent courses, even before prophylaxis (8/35 samples, 22.9% before the first course vs 20/33 samples, 60.6% before the second and subsequent courses, P=0.003). The incomplete recovery of the initial bacterial composition was associated with a prophylactic interval of within 30 days. Of the patients receiving multiple prophylactic courses, six had QR Escherichia coli, including extended-spectrum β-lactamase (ESBL) producers, at the first course, and four (66.3%) of the six patients had persistent detection of QR E. coli at the second course.ConclusionIn patients receiving multiple courses of prophylactic quinolone, along with a common chemotherapy schedule, newly emergent resistant bacteria could be frequently persistent in their fecal flora.

Levaquin Gets a Pass

“…Evaluation of antibiotic resistance and differentiation of total versus relative taxa abundances was not possible by 16S rRNA gene sequencing in our study. In a previous study, in a cohort of patients with hematologic malignancies and NF, stool samples collected before LEVO exposure showed a lower rate of positivity on culture for quinolone-resistant coagulase-negative Staphylococcus and Enterococcus [19]. A previous study of stool samples collected from patients with acute myeloid leukemia or multiple myeloma for the evaluation of diarrhea did not find a difference in a diversity or in the relative abundance of Enterococcus and Clostridia between samples collected without versus with preceding LEVO exposure [11].…”

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

“…Additionally, detection of quinolone‐resistant CoNS and Enterococci significantly increased in subsequent courses. Overall, these data showed incomplete recovery of the gut flora with persistence of resistant bacterial colonization in patients receiving multiple courses of fluoroquinolone prophylaxis 76 …”

Prophylactic antibiotics on patients with cirrhosis and upper gastrointestinal bleeding: A meta-analysis

“…However, some studies have presented evidence suggesting that oral quinolone administration may not be the best regime for the prevention of bacterial infections in cirrhotic patients with gastrointestinal hemorrhage. The prevalence of quinolone-resistant bacteria in the fecal flora [ 42 , 43 ] and the incidence of spontaneous bacterial peritonitis (SBP) [ 44 ], and other infections [ 45 ] caused by these organisms have increased substantially. In this case, other classes of antibiotics are needed.…”