Data on the impact of empiric febrile neutropenia (FN) guidelines on resistant bacteria in pediatric oncology patients are limited. We implemented a risk-stratified guideline for empiric FN antibiotics, limiting vancomycin use to high-risk patients for 48 hours if cultures were negative. Our aim was to assess the impact of this intervention on rates of vancomycin-resistant Enterococcus (VRE) and vancomycin use.
We conducted a retrospective, quasi-experimental study of oncology patients ≤ 18 years with FN admitted from 2010 - 2014. Microbiologic data and inpatient antibiotic use were obtained by chart review. Risk strata incorporated diagnosis, chemotherapy phase, Down syndrome, septic shock, and typhlitis. The primary outcome was VRE incidence; all VRE isolates were included but active surveillance was only performed in intensive care units (ICUs) in both periods. We compared VRE incidence and antibiotic days of therapy (DOT) before and after the intervention using interrupted time-series analysis with segmented Poisson regression with auto-correlation.
We identified 183 patients with 765 admissions and 382 FN episodes pre-intervention, and 185 patients with 830 admissions and 385 FN episodes post-intervention. The proportion of high-risk patients was 51% pre vs. 45% post (P=0.06). Median length of stay for FN admissions was 7 days (IQR: 4-22) pre-intervention and 5 days (IQR: 3-15) post-intervention (P≤0.01). Median duration of empiric vancomycin decreased from 5 days (IQR: 3-9) pre- to 3 days (IQR: 3-4) post-intervention (P≤0.01). Empiric vancomycin DOT/1000 FN days decreased from 287 pre-intervention to 199 post-intervention (P≤0.01). Incidence of VRE/1000 patient days decreased significantly from 1.71 pre-intervention to 0.45 post-intervention (IRR=0.26, 95% CI 0.09-0.80; P=0.02). The proportion of VRE isolates representing colonization did not differ significantly pre- and post-intervention (50% vs. 67%).
Implementation of a FN guideline limiting vancomycin exposure was associated with decreased incidence of VRE among pediatric oncology patients. Antimicrobial stewardship interventions are feasible in immunocompromised patients and can impact antibiotic resistance.
R. Zaboulian, None
T. Sharma, None
A. Place, None
T. J. Sandora, None
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