[Evaluation of three types of empirical antibiotherapy in patients with febrile neutropenia: imipenem-cilastatin versus ceftazidime-vancomycin versus ticarcillin-amikacin-vancomycin].
A three-arm prospective randomized trial was designed to compare the effectiveness of single drug therapy with imipenemcilastatin (IC), two-drug therapy with ceftazidime-vancomycin (CV), and three-drug therapy with ticarcillin-vancomycin-amikacin (TVA) for the empirical antimicrobial treatment of febrile neutropenia events. The objectives of the study were to determine whether IC monotherapy was as effective as combination drug therapy (CV or TVA) and to assess the value of adding vancomycin at initiation of treatment. One hundred eighty-three febrile neutropenia events were randomized and 125 were evaluable. Success rates were 73% with IC, 67% with CV, and 72% with TVA. There were no statistically significant differences between the three treatment groups, regardless of the duration and severity of neutropenia. Fifty-four bacterial isolates were recovered from 43 patients. Among recovered bacterial strains, 55% were Gram-negative and 45% were Gram-positive. Rates of bacteriologically documented failures (14/33) and superinfections (3/33) were similar in the three groups. Adverse events were rare but two patients given CV and three given TVA developed severe skin toxicity requiring modification of the antimicrobial regimen. IC alone showed similar effectiveness and less toxicity, as compared with CV or TVA. Vancomycin given initially increased toxicity but failed to improve the success rate. Vancomycin may be appropriate only in patients at high risk for infection with methicillin-resistant staphylococci.
Bosseray
A
A
Clinique Médicale et des Maladies Infectieuses, CHRU 38043, Grenoble, France.
Nicolini
F
F
Brion
J P
JP
Michallet
M
M
Hollard
D
D
Stahl
J P
JP
Micoud
M
M
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000583:Amikacin / Q000627:therapeutic use; D001424:Bacterial Infections / Q000188:drug therapy / Q000382:microbiology; D002442:Ceftazidime / Q000627:therapeutic use*; D015377:Cilastatin / Q000627:therapeutic use*; D004359:Drug Therapy, Combination / Q000627:therapeutic use; D005260:Female; D006801:Humans; D015378:Imipenem / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009503:Neutropenia / Q000188:drug therapy; D011446:Prospective Studies; D013982:Ticarcillin / Q000627:therapeutic use*; D014640:Vancomycin / Q000627:therapeutic use*
D015377:Cilastatin; D014640:Vancomycin; D015378:Imipenem; D000583:Amikacin; D002442:Ceftazidime; D013982:Ticarcillin
Evaluation de trois types d'antibiothérapie empirique chez le patient neutropénique fébrile: imipénème-cilastatine versus ceftazidime plus vancomycine versus ticarcilline plus amikacine plus vancomycine.