METRONOMIC FIRST-LINE ANTIBIOTICS FOR FEBRILE NEUTROPENIA – IMPACT ON ECOLOGY AND MORTALITY IN PATIENTS TREATED FOR HAEMATOLOGIC MALIGNANCIES
(Abstract release date: 05/19/16)
EHA Library. Wong G. 06/09/16; 132720; E1171
Assoc. Prof. Gee Chuan Wong
Contributions
Contributions
Abstract
Abstract: E1171
Type: Eposter Presentation
Background
Rising antibiotic resistance threatens to limit our choices for empirical and definitive treatment of febrile neutropenia (FN). Reports suggest that increasing antibiotic heterogeneity might be associated with a decline in resistance. In our hospital's Haematology unit, cefepime (CEF) was recommended as the first-line empirical antibiotic in FN. Rising drug resistance and the potential usefulness of increasing antibiotic diversity led us to re-consider our approach.
Aims
To introduce antibiotic heterogeneity by alternating use of first-line antibiotics and to determine the impact of this on ecology and mortality of patients treated for haematological malignancies.
Methods
From mid-2013, a new FN guideline was implemented. Neutropenic patients who developed fever on odd dates of the month would be given Piperacillin Tazobactam (PTZ) and on even dates, a combination of Cefepime and Amikacin, post blood cultures. This is termed as “metronomic 1st line antibiotics”. If fever persists after 48 hours, physicians could continue on the same antibiotics, or add vancomycin or switch to meropenem (MER).To assess the impact of this change, we collected the following data for the years 2012 and 2014: rates of bacteremia (including rates of bacteremia caused by carbapenem-resistant organisms), Methicillin Resistant Staphilococcus Aureus (MRSA) acquisition, Vancomycin Resistant Enterococcus (VRE) acquisition, mortality. We also calculated the defined daily doses (DDD) of CEF, PTZ, and MER for 2012 and 2014. This study was approved by the Institution Review Board.
Results
In 2012, 1183 patients were admitted 2012 times; in 2014, 1112 patients were admitted 1843 times. Males formed 54.5% and 55.7% of the patients in 2012 and 2014 respectively. The following were similar (p>0.5) in the 2 years: mean and median ages of the patients, number of new patients with acute myeloid leukemia (AML) and acute lymphocytic leukemia (ALL) who started on chemotherapy, spread of discharge diagnoses (AML, ALL, myeloma, lymphoma). Rate (DDD/1000 days) of CEF use fell (p<0.001) and rate of PTZ use rose (p<0.001) in 2014. Rate of MER use was unchanged. Bacteremia rates were unchanged. Rates of acquisition of MRSA and VRE were unchanged. Rates of CEF-resistant, and of PTZ-resistant E. coli, Klebsiella spp, and P. aeruginosa isolated from blood cultures were similar in the 2 years. The rate of carbapenem-resistant P. aeruginosa was 12.7% in 2012 and 17.5% in 2014 (p=0.6). Mortality among bacteremic patients was 24% in 2012, 14% in 2014 (p=0.001).
Conclusion
We conclude that “metronomic 1st line antibiotics” introduced an element of antibiotic heterogeneity. This was not associated with an increase in the rate of isolation of resistant organisms. It is possible that the increased use of PTZ was associated with a lower mortality.
Session topic: E-poster
Keyword(s): Febrile neutropenia, Leukemia, Mortality, Resistance
Type: Eposter Presentation
Background
Rising antibiotic resistance threatens to limit our choices for empirical and definitive treatment of febrile neutropenia (FN). Reports suggest that increasing antibiotic heterogeneity might be associated with a decline in resistance. In our hospital's Haematology unit, cefepime (CEF) was recommended as the first-line empirical antibiotic in FN. Rising drug resistance and the potential usefulness of increasing antibiotic diversity led us to re-consider our approach.
Aims
To introduce antibiotic heterogeneity by alternating use of first-line antibiotics and to determine the impact of this on ecology and mortality of patients treated for haematological malignancies.
Methods
From mid-2013, a new FN guideline was implemented. Neutropenic patients who developed fever on odd dates of the month would be given Piperacillin Tazobactam (PTZ) and on even dates, a combination of Cefepime and Amikacin, post blood cultures. This is termed as “metronomic 1st line antibiotics”. If fever persists after 48 hours, physicians could continue on the same antibiotics, or add vancomycin or switch to meropenem (MER).To assess the impact of this change, we collected the following data for the years 2012 and 2014: rates of bacteremia (including rates of bacteremia caused by carbapenem-resistant organisms), Methicillin Resistant Staphilococcus Aureus (MRSA) acquisition, Vancomycin Resistant Enterococcus (VRE) acquisition, mortality. We also calculated the defined daily doses (DDD) of CEF, PTZ, and MER for 2012 and 2014. This study was approved by the Institution Review Board.
Results
In 2012, 1183 patients were admitted 2012 times; in 2014, 1112 patients were admitted 1843 times. Males formed 54.5% and 55.7% of the patients in 2012 and 2014 respectively. The following were similar (p>0.5) in the 2 years: mean and median ages of the patients, number of new patients with acute myeloid leukemia (AML) and acute lymphocytic leukemia (ALL) who started on chemotherapy, spread of discharge diagnoses (AML, ALL, myeloma, lymphoma). Rate (DDD/1000 days) of CEF use fell (p<0.001) and rate of PTZ use rose (p<0.001) in 2014. Rate of MER use was unchanged. Bacteremia rates were unchanged. Rates of acquisition of MRSA and VRE were unchanged. Rates of CEF-resistant, and of PTZ-resistant E. coli, Klebsiella spp, and P. aeruginosa isolated from blood cultures were similar in the 2 years. The rate of carbapenem-resistant P. aeruginosa was 12.7% in 2012 and 17.5% in 2014 (p=0.6). Mortality among bacteremic patients was 24% in 2012, 14% in 2014 (p=0.001).
Conclusion
We conclude that “metronomic 1st line antibiotics” introduced an element of antibiotic heterogeneity. This was not associated with an increase in the rate of isolation of resistant organisms. It is possible that the increased use of PTZ was associated with a lower mortality.
Session topic: E-poster
Keyword(s): Febrile neutropenia, Leukemia, Mortality, Resistance
Abstract: E1171
Type: Eposter Presentation
Background
Rising antibiotic resistance threatens to limit our choices for empirical and definitive treatment of febrile neutropenia (FN). Reports suggest that increasing antibiotic heterogeneity might be associated with a decline in resistance. In our hospital's Haematology unit, cefepime (CEF) was recommended as the first-line empirical antibiotic in FN. Rising drug resistance and the potential usefulness of increasing antibiotic diversity led us to re-consider our approach.
Aims
To introduce antibiotic heterogeneity by alternating use of first-line antibiotics and to determine the impact of this on ecology and mortality of patients treated for haematological malignancies.
Methods
From mid-2013, a new FN guideline was implemented. Neutropenic patients who developed fever on odd dates of the month would be given Piperacillin Tazobactam (PTZ) and on even dates, a combination of Cefepime and Amikacin, post blood cultures. This is termed as “metronomic 1st line antibiotics”. If fever persists after 48 hours, physicians could continue on the same antibiotics, or add vancomycin or switch to meropenem (MER).To assess the impact of this change, we collected the following data for the years 2012 and 2014: rates of bacteremia (including rates of bacteremia caused by carbapenem-resistant organisms), Methicillin Resistant Staphilococcus Aureus (MRSA) acquisition, Vancomycin Resistant Enterococcus (VRE) acquisition, mortality. We also calculated the defined daily doses (DDD) of CEF, PTZ, and MER for 2012 and 2014. This study was approved by the Institution Review Board.
Results
In 2012, 1183 patients were admitted 2012 times; in 2014, 1112 patients were admitted 1843 times. Males formed 54.5% and 55.7% of the patients in 2012 and 2014 respectively. The following were similar (p>0.5) in the 2 years: mean and median ages of the patients, number of new patients with acute myeloid leukemia (AML) and acute lymphocytic leukemia (ALL) who started on chemotherapy, spread of discharge diagnoses (AML, ALL, myeloma, lymphoma). Rate (DDD/1000 days) of CEF use fell (p<0.001) and rate of PTZ use rose (p<0.001) in 2014. Rate of MER use was unchanged. Bacteremia rates were unchanged. Rates of acquisition of MRSA and VRE were unchanged. Rates of CEF-resistant, and of PTZ-resistant E. coli, Klebsiella spp, and P. aeruginosa isolated from blood cultures were similar in the 2 years. The rate of carbapenem-resistant P. aeruginosa was 12.7% in 2012 and 17.5% in 2014 (p=0.6). Mortality among bacteremic patients was 24% in 2012, 14% in 2014 (p=0.001).
Conclusion
We conclude that “metronomic 1st line antibiotics” introduced an element of antibiotic heterogeneity. This was not associated with an increase in the rate of isolation of resistant organisms. It is possible that the increased use of PTZ was associated with a lower mortality.
Session topic: E-poster
Keyword(s): Febrile neutropenia, Leukemia, Mortality, Resistance
Type: Eposter Presentation
Background
Rising antibiotic resistance threatens to limit our choices for empirical and definitive treatment of febrile neutropenia (FN). Reports suggest that increasing antibiotic heterogeneity might be associated with a decline in resistance. In our hospital's Haematology unit, cefepime (CEF) was recommended as the first-line empirical antibiotic in FN. Rising drug resistance and the potential usefulness of increasing antibiotic diversity led us to re-consider our approach.
Aims
To introduce antibiotic heterogeneity by alternating use of first-line antibiotics and to determine the impact of this on ecology and mortality of patients treated for haematological malignancies.
Methods
From mid-2013, a new FN guideline was implemented. Neutropenic patients who developed fever on odd dates of the month would be given Piperacillin Tazobactam (PTZ) and on even dates, a combination of Cefepime and Amikacin, post blood cultures. This is termed as “metronomic 1st line antibiotics”. If fever persists after 48 hours, physicians could continue on the same antibiotics, or add vancomycin or switch to meropenem (MER).To assess the impact of this change, we collected the following data for the years 2012 and 2014: rates of bacteremia (including rates of bacteremia caused by carbapenem-resistant organisms), Methicillin Resistant Staphilococcus Aureus (MRSA) acquisition, Vancomycin Resistant Enterococcus (VRE) acquisition, mortality. We also calculated the defined daily doses (DDD) of CEF, PTZ, and MER for 2012 and 2014. This study was approved by the Institution Review Board.
Results
In 2012, 1183 patients were admitted 2012 times; in 2014, 1112 patients were admitted 1843 times. Males formed 54.5% and 55.7% of the patients in 2012 and 2014 respectively. The following were similar (p>0.5) in the 2 years: mean and median ages of the patients, number of new patients with acute myeloid leukemia (AML) and acute lymphocytic leukemia (ALL) who started on chemotherapy, spread of discharge diagnoses (AML, ALL, myeloma, lymphoma). Rate (DDD/1000 days) of CEF use fell (p<0.001) and rate of PTZ use rose (p<0.001) in 2014. Rate of MER use was unchanged. Bacteremia rates were unchanged. Rates of acquisition of MRSA and VRE were unchanged. Rates of CEF-resistant, and of PTZ-resistant E. coli, Klebsiella spp, and P. aeruginosa isolated from blood cultures were similar in the 2 years. The rate of carbapenem-resistant P. aeruginosa was 12.7% in 2012 and 17.5% in 2014 (p=0.6). Mortality among bacteremic patients was 24% in 2012, 14% in 2014 (p=0.001).
Conclusion
We conclude that “metronomic 1st line antibiotics” introduced an element of antibiotic heterogeneity. This was not associated with an increase in the rate of isolation of resistant organisms. It is possible that the increased use of PTZ was associated with a lower mortality.
Session topic: E-poster
Keyword(s): Febrile neutropenia, Leukemia, Mortality, Resistance
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