Inpatient Antibiotic Stewardship Interventions in the Adult Oncology and Hematopoietic Stem Cell Transplant Population: A Review of the Literature

Abstract

Objective: To review the use of antibiotic stewardship interventions in the adult oncology and hematopoietic cell transplantation (HCT) populations. Data Sources: A literature search of PubMed was performed from inception to October 31, 2019. The general search terms used were oncology, cancer, hematologic malignancy, antimicrobial stewardship, antibiotic stewardship, febrile neutropenia, neutropenic fever, de-escalation, discontinuation, prophylaxis, practice guidelines, clinical pathway, rapid diagnostics, Filmarray, Verigene, MALDI-TOF, antibiotic allergy, and antimicrobial resistance. Study Selection and Data Extraction: Relevant English-language studies describing interventions supported by the Infectious Diseases Society of America guidelines on “Implementing an Antibiotic Stewardship Program” were included. Data Synthesis: Antibiotic stewardship publications in the oncology population have increased in recent years. Studies have described the impact of stewardship interventions, including preauthorization, prospective audit and feedback, implementation of clinical pathways, de-escalation of empirical antibiotics for febrile neutropenia (FN) prior to neutrophil recovery, allergy assessments, and use of rapid diagnostic testing. Many of these interventions have been shown to decrease antibiotic use without increased negative consequences, such as affecting length of stay or mortality. Relevance to Patient Care and Clinical Practice: This review synthesizes available evidence for implementing antibiotic stewardship interventions, particularly de-escalation of antibiotics for FN and implementation of clinical pathways for FN and sepsis, in oncology patients and HCT recipients. Summary tables highlight studies and specific research needs for clinicians. Conclusions: Immunocompromised populations, including oncology patients, have often been excluded from stewardship studies. Antibiotic stewardship is effective in reducing antibiotic consumption and improving outcomes in this patient population, although more quality data are needed.

Antibiotic-induced disruption of the microbiome exacerbates chemotherapy-induced diarrhoea and can be mitigated with autologous faecal microbiota transplantation

“…Although the antibiotic schedule used in our study was not intended to reflect clinical practice, when viewed alongside the growing body of literature, our findings raise important implications for antibiotic stewardship. Specifically, they highlight the need to select appropriate prophylactic antimicrobial drugs that do not damage the microbiome [46]. Ciprofloxacin is reported to have mild effects on the microbiome and may therefore be a potential avenue to restrict antibiotics whilst still providing appropriate infection control [47].…”

Optimising Antimicrobial Selection and Duration in the Treatment of Febrile Neutropenia in Children

“…To combat these concerns, diagnostic and AMS principles should be embedded within FN guidelines to ensure the right investigations are done and interpretation of these inform the right antibiotic choice and duration. 47,48 Comprehensive and collaborative AMS interventions have been shown to reduce antibiotic exposure in immunocompromised patients without compromising patient safety and are vital to limiting the impact of AMR. 47,[49][50][51]…”

Antibiotic resistance in the patient with cancer: Escalating challenges and paths forward

“…164 However, according to a review published by Pillinger et al in 2020, these patient populations are frequently excluded from studies of antibiotic stewardship, and more efforts are needed to determine the broader impact of different stewardship strategies in this vulnerable patient population. 165 Nevertheless, several other studies in hospital-wide intervention programs have demonstrated the impact of antibiotic stewardship on decreasing antibiotic resistance system wide and reducing antimicrobial expenditures. [166][167][168][169][170] Although more data in this patient population are needed, it is reasonable to conclude that decreases in infections caused by antibiotic-resistant pathogens in a health care system would translate to improved outcomes across a diverse range of patient populations.…”