Antibiotic rotation for febrile neutropenic patients with hematological malignancies: clinical significance of antibiotic heterogeneity.
BACKGROUND
Our unit adopted the single administration of cefepime as the initial treatment for febrile episodes in neutropenic patients with hematological malignancies. However, recently, cefepime-resistant gram-negative bacteremia, including those with extended-spectrum β-lactamase (ESBL)-producers, was frequently observed in these patients. Therefore, we instituted a rotation of primary antibiotics for febrile neutropenic patients in an attempt to control antibiotic resistance.


METHODS
This prospective trial was performed from August 2008 through March 2011 at our unit. After a pre-intervention period, in which cefepime was used as the initial agent for febrile neutropenia, 4 primary antibiotics, namely, piperacillin-tazobactam, ciprofloxacin, meropenem, and cefepime, were rotated at 1-month intervals over 20 months. Blood and surveillance cultures were conducted for febrile episodes, in order to assess the etiology, the resistance pattern (particularly to cefepime), and the prognosis.


RESULTS
In this trial, 219 patients were registered. A 65.9% reduction in the use of cefepime occurred after the antibiotic rotation. In the surveillance stool cultures, the detection rate of cefepime-resistant gram-negative isolates, of which ESBL-producers were predominant, declined significantly after the intervention (8.5 vs 0.9 episodes per 1000 patient days before and after intervention respectively, P<0.01). Interestingly, ESBL-related bacteremia was not detected after the initiation of the trial (1.7 vs 0.0 episodes per 1000 patient days before and after intervention respectively, P<0.01). Infection-related mortality was comparable between the 2 periods.


CONCLUSIONS
We implemented a monthly rotation of primary antibiotics for febrile neutropenic patients. An antibiotic heterogeneity strategy, mainly performed as a cycling regimen, would be useful for controlling antimicrobial resistance among patients treated for febrile neutropenia.
Department of Medicine and Biosystemic Sciences, Kyushu University Graduate School of Medicine, Fukuoka, Japan. ychong@gj9.so-net.ne.jp
Yong
Y
Chong
Shinji
S
Shimoda
Hiroko
H
Yakushiji
Yoshikiyo
Y
Ito
Toshihiro
T
Miyamoto
Tomohiko
T
Kamimura
Nobuyuki
N
Shimono
Koichi
K
Akashi
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use*; D016470:Bacteremia / Q000150:complications / Q000188:drug therapy* / Q000382:microbiology; D000077723:Cefepime; D002511:Cephalosporins / Q000494:pharmacology / Q000627:therapeutic use; D002939:Ciprofloxacin / Q000494:pharmacology / Q000627:therapeutic use; D004334:Drug Administration Schedule; D005260:Female; D005334:Fever / Q000150:complications / Q000188:drug therapy* / Q000382:microbiology; D016905:Gram-Negative Bacterial Infections / Q000150:complications / Q000188:drug therapy* / Q000382:microbiology; D019337:Hematologic Neoplasms / Q000150:complications / Q000188:drug therapy* / Q000382:microbiology; D006801:Humans; D008297:Male; D000077731:Meropenem; D008875:Middle Aged; D009503:Neutropenia / Q000150:complications / Q000188:drug therapy* / Q000382:microbiology; D010397:Penicillanic Acid / Q000031:analogs & derivatives / Q000494:pharmacology / Q000627:therapeutic use; D010878:Piperacillin / Q000494:pharmacology / Q000627:therapeutic use; D000077725:Piperacillin, Tazobactam Drug Combination; D011446:Prospective Studies; D013845:Thienamycins / Q000494:pharmacology / Q000627:therapeutic use; D018440:beta-Lactam Resistance / Q000187:drug effects
D000900:Anti-Bacterial Agents; D002511:Cephalosporins; D013845:Thienamycins; D000077725:Piperacillin, Tazobactam Drug Combination; D002939:Ciprofloxacin; D000077723:Cefepime; D010397:Penicillanic Acid; D000077731:Meropenem; D010878:Piperacillin