The IDSA and NCCN guidelines recommend continuing IV anti-pseudomonal (IVPSA) therapy until neutrophil recovery (i.e. an ANC > 500 cells/mm3) in high-risk acute myeloid leukemia (AML) patients with febrile neutropenia (FN). This recommendation is based on expert opinion and the current practice should be re-evaluated given the emergence of multi-drug resistant organisms and high rates of Clostridium difficile infection (CDI) in this population. The purpose of this study was to evaluate whether IVPSA antibiotics could be safely de-escalated or discontinued in high-risk AML patients with FN following implementation of a guideline.
This single-center, pre-post quasi-experimental study included patients with AML receiving induction chemotherapy hospitalized between September 2015 to February 2018. Patients in the intervention group were compared to a historical cohort of patients admitted before implementation of the guideline. The primary outcome was the incidence of suspected or documented bacterial infection after antibiotic de-escalation in the intervention group (or meeting criteria for de-escalation in the historical control group). Secondary outcomes included the incidence of CDI, IVPSA Days of Therapy (DOTs), hospital length of stay (LOS), and mortality. Patients in the intervention group were evaluated for antibiotic de-escalation on day 5 of FN and antibiotics were discontinued if patients were afebrile, hemodynamically stable, and without evidence of infection irrespective of their ANC (or de-escalated to fluoroquinolone prophylaxis in relapsed/refractory disease). In clinically stable patients with suspected or documented bacterial infection, antibiotics were continued for a defined duration per indication as outlined in the guideline.
A total of 93 patients were included in the analysis. Baseline demographics were similar between the two groups with the exception of more relapsed/refractory patients in the intervention group. Patients in the intervention group had similar clinical outcomes and lower rates of CDI and IVPSA DOTs (see figure 1).
In high-risk AML patients with FN, an antibiotic de-escalation guideline reduced the incidence of CDI and IVPSA antibiotic DOTs without adversely affecting clinical outcomes.
A. J. Perissinotti, None
D. Bixby, None
K. Gregg, None
J. Nagel, None