Quinolone resistance in neutropenic patients: the effect of prescribing policy in the UK and Pakistan

Abstract

Quinolones are increasingly used as prophylaxis in neutropenic patients to prevent serious Gram-negative septicaemias but practice is not uniform because of the controversial evidence as to their effectiveness. It is unclear if they are of real benefit in patients with short episodes of neutropenia such as those resulting from treatment for solid tumours and lymphomas. The concern over the use of ciprofloxacin in such settings is the increasing development of quinolone resistant Gram-negative bacteria. We have retrospectively analysed our bacterial isolate resistance patterns in the Queen Elizabeth Hospital (QE) and in the Haematology Department of the Aga Khan Hospital (AKU), Pakistan where all patients would receive ciprofloxacin prophylaxis when neutropenic. Seven out of 57 (12.2%) and 18 out of 55 (32.7%) Gram-negative organisms isolated from blood cultures at the QE and AKU Haematology Departments, respectively, were resistant to ciprofloxacin (P < 0.01). In the Birmingham community this was significantly lower (P < 0.01) (55 out of 6423: 0.85%). We also showed a higher level of E. coli resistance at the AKU (18 out of 31: 58%) where ciprofloxacin use was more widespread than at the QE (1 out of 11, P < 0.01). We conclude that ciprofloxacin should not be used indiscriminately.

Bacteraemia in Europe—antimicrobial susceptibility data from the MYSTIC surveillance programme

“…This difference from the other antimicrobials was most marked for E. coli, one of the commonest bacteraemic pathogens, and may be due to the regular prophylactic use of CIP in the hospital setting, particularly for the treatment of neutropenia patients [27].…”

A pilot study of prophylactic ciprofloxacin during delayed intensification in children with acute lymphoblastic leukemia

“…There is growing concern regarding emerging drug resistant bacteria 17–21. It is for this reason that the Infectious Diseases Society of America advocates against routine prophylaxis 17.…”

“…Since the study used historical controls, factors other than ciprofloxacin may have contributed to these findings. The major disadvantage of prophylactic antibiotic therapy is the emergence of drug resistance 17–21. Any such disadvantage must be weighed against the potential benefit of decreasing the episodes of febrile neutropenia and Gram‐negative bacteremias.…”

“…Prophylactic antibiotic therapy given during myelosuppressive chemotherapy in adult cancers, including leukemia, decreases the rate of Gram‐negative bacteremia 5–16. However, the indications for antibiotic prophylaxis remain controversial, primarily because of the risk of developing antibiotic resistance 17–21. The greatest incidence of febrile neutropenia in childhood ALL occurs during induction and following DI.…”

Catheter‐related bloodstream infections in hematology

“…2,3 Standardized surveillance measures have not been used to assess interventions with potential impact on the epidemiology of CR-BSIs. For example, widespread use of antibiotic lock therapy, 4 antimicrobial-impregnated catheters, 5 or quinolone prophylaxis 6 by individual centers could influence the rate, etiology, and susceptibility of CR-BSIs, affecting choice of empiric or first-line antimicrobial therapy. Demonstrated efficacy under controlled conditions of clinical trials does not necessarily equate to improved outcomes in routine practice, 7 and population-based surveillance is a necessary step in monitoring the effectiveness of new or changing healthcare practice.…”