Earlier Antipseudomonal De-escalation Is a Possibility in AML, Neutropenia

Patients with acute myeloid leukemia (AML) and febrile neutropenia (FN) that are de-escalated on day 5 if they were afebrile, hemodynamically stable, and without evidence of infection, had similar clinical outcomes and a decreased incidence of Clostridium difficile (C difficile) infections compared with patients without these early on re-evaluations for de-escalation.

Patients with AML and FN need to be treated with dedicated care due to their immunosuppressed state. Both the Infectious Disease Society of America and National Comprehensive Cancer Network guidelines recommend continuing intravenous antipseudomonal therapy (IVPSA) until neutrophil recovery, defined as an absolute neutrophil count (ANC) > 500 cells/mm³. However, this standard of practice is being re-evaluated because of the increasing rates of multidrug­-resistant organisms and C difficile infection. To determine if the benefits of longer IVPSA therapy outweigh the risks, Alegria et al conducted an experimental study on whether IVPSA de-escalation affected patient outcomes.

Patients with AML were compared in 2 groups, the intervention and historical group. The historical group were patients who were enrolled before implementation of the guideline. In contrast, the intervention group were patients who were evaluated for antibiotic de-escalation on day 5 if they were afebrile, hemodynamically stable, and without evidence of infection, irrespective of their ANC.

What are the discharge guidelines for pediatric patients with febrile neutropenia?

Ninety-three patients with AML were included in this study (40 patients in the historical group, 53 patients in the intervention group). Between the 2 groups, clinical outcomes were very similar, except for the lower rates of C difficile infection and the shorter duration of IVPSA for the intervention group. Bacterial infection rates after antibiotic de-escalation were comparable, with 18 patients (45%) in the historical group and 18 patients (34%) in the intervention group (P = .292).

Similarly, the hospital length of stay (LOS) was not significantly different between the 2 groups (historical group, 25 days and intervention group, 27 days; P = .757). The incidence of C difficile infection, however, was significantly less in the intervention group (n = 3, 5.7%) than the historical group (n = 11, 27.5%; P = .007). Also, the duration of IVPSA was significantly less for the intervention group (14 days) compared with the historical group (25 days; P < .001).

The inappropriate use of antibiotics has resulted in an increase in C difficile infection and multidrug resistant organisms, leading to higher mortality for most of these immunosuppressed populations. By implementing a guideline to re-evaluate the need of IVPSA earlier on, patients can expect a decreased incidence of C difficile infection and a shorter duration of IVPSA therapy, while still effectively treating the infection.

Reference

Alegria W, Marini BL, Perissinotti AJ, Bixby D, Gregg K, Nagel J. Febrile neutropenia antibiotic de-escalation study in acute myeloid leukemia patients with prolonged neutropenia. In: Antimicrobial Stewardship: Special Populations; October 4, 2018; San Francisco, CA. Abstract 253. https://idsa.confex.com/idsa/2018/webprogram/Paper71717.html.