Monotherapy Vs expanded regimen of antibiotics for neutropenic fever

The decision to initially use intravenous (IV) monotherapy vs an expanded regimen of antibiotics depends on the severity of illness....

The use of EMPIRICAL ANTIMICROBIAL treatment as part of the management of fever and neutropenia decreases the risk of progression to sepsis, septic shock, acute respiratory distress syndrome, organ dysfunction, and death. In 2010 the Infectious Diseases Society of America (IDSA) updated a comprehensive guideline for the use of antimicrobial agents in neutropenic children and adults with cancer. The decision to initially use intravenous (IV) monotherapy vs an expanded regimen of antibiotics depends on the severity of illness of the patient, history of previous colonization with resistant organisms, and obvious presence of catheter-related infection.

Vancomycin should be added to the initial empirical regimen if:

The patient has hypotension or other evidence of septic shock.
Obvious catheter-related infection.
History of colonization with methicillin-resistant S. aureus.
The patient is at high risk for viridans streptococci (severe mucositis, acute myelogenous leukemia, or prior use of quinolone prophylaxis).

Otherwise, use of monotherapy with an antibiotic such as cefepime (Maxipime) or piperacillin-tazobactam (Tazocin) can be considered. Ceftazidime (Fortum) should not be used as monotherapy if concern exists for gram-positive organisms or resistant gram-negative bacteria. Carbapenems such as imipenem/cilastin (Tienam) and meropenem (Meronem) should not be first line, aiming to prevent pressure on carbapenem-resistant Enterobacteriaceae. The addition of a 2nd anti–gram-negative bacterial agent (e.g., aminoglycoside) for empirical therapy can be considered in patients who are clinically unstable when multidrug-resistant organisms are suspected.

Antibiotic discontinuation. Patients who have negative blood cultures at 48 hr, who have been afebrile for at least 24 hr, and who have evidence of bone marrow recovery (ANC > 100 cells/mm³) can have antibiotics discontinued. However, if symptoms persist or evolve, IV antibiotics should be continued. The 2012 pediatric guidelines advocate for discontinuing antibiotics in low-risk patients at 72 hr for children who have negative blood cultures and who have been afebrile for at least 24 hr regardless of bone marrow recovery, as long as careful follow-up is ensured. In contrast, others continue to advocate for continuing antibiotics in this circumstance to prevent recurrence of fever.

References

Neutropenic Patients with Cancer. Clinical Infectious Diseases, Volume 52, Issue 4, 15 February 2011,[online] Available at: https://www.idsociety.org/practice-guideline/neutropenic-patients-with-cancer

Baluch, A. and Shewayish, S. (2019). Neutropenic Fever. Infections in Neutropenic Cancer Patients, [online] pp.105–117. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7120136

Lehrnbecher T, Phillips R, Alexander S, Alvaro F, Carlesse F, Fisher B, Hakim H, Santolaya M, Castagnola E, Davis BL, Dupuis LL, Gibson F, Groll AH, Gaur A, Gupta A, Kebudi R, Petrilli S, Steinbach WJ, Villarroel M, Zaoutis T, Sung L; International Pediatric Fever and Neutropenia Guideline Panel. Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation. J Clin Oncol. 2012 Dec 10;30(35):4427-38. Available at: https://pubmed.ncbi.nlm.nih.gov/22987086