Discontinuation of empirical antibiotic therapy in neutropenic acute myeloid leukaemia patients with fever of unknown origin: is it ethical?

Abstract

Based on recommendations of the ECIL-4, we prospectively evaluated discontinuation of empirical antibiotic therapy in high-risk neutropenic acute myeloid leukaemia patients with fever of unknown origin. Seven patients (median neutropenia duration 30 days) were included. Four of them remained afebrile but quickly recovered from neutropenia. The other three had rapid recurrent fever. Two of these three patients had bacteraemia with susceptible strains and one of them was transferred to the ICU for septic shock. Median duration of sparing of antibiotics for the seven patients was 3 days (2-4). Because of these limited results the study was stopped.

Early Antimicrobial De-escalation and Stewardship in Adult Hematopoietic Stem Cell Transplantation Recipients: Retrospective Review

“…While some variation exists in the trial designs, all demonstrate very low rates of mortality after early de-escalation or discontinuation of broad-spectrum antimicrobials in neutropenic fever treatment, even in those patients with recurrent febrile episodes. On the contrary, a study by Micol et al found a high rate of bacteremia (2 of 7, 29%) after early antibiotic discontinuation [ 30 ]. While concerning, the study design and conclusions had several limitations, including the small population of 7 patients that stopped early, extremely restrictive criteria for discontinuation, failure to acknowledge that the rate of recurrent fever can be frequent in patients whether they remain on broad-spectrum therapy or not, and incorrect assumption that continuing broad-spectrum antibiotics unnecessarily will do no harm to the patient.…”

Discontinuation of empirical antibiotic therapy in neutropenic leukaemia patients with fever of unknown origin is ethical

“…We read with interest the Note by Micol et al [1] challenging ECIL's recommendation to discontinue empirical antibiotics after resolution of fever of unknown origin (FUO) in high-risk haematologic patients despite persistent neutropenia. We reply for the ECIL panel, whose guidance states that empiric antibiotics can be discontinued after 72 hours .…”

De-Escalation and Discontinuation of Empirical Antibiotic Treatment in a Cohort of Allogeneic Hematopoietic Stem Cell Transplantation Recipients during the Pre-Engraftment Period

“…Although our approach did not standardize the time of discontinuation, it was performed in 32% of patients, and none of patients who failed discontinuation and needed to restart antibiotic therapy developed septic shock or died. On the contrary, Micol et al [16] prematurely interrupted their study in neutropenic patients with acute myeloid leukemia and fever of unknown origin because 3 of 7 patients demonstrated fever relapse within 3 days from antibiotic discontinuation and 1 developed septic shock. However, these results are in contrast with a retrospective study in neutropenic patients and our experience, in which 19% and 17.5% of patients needed subsequent escalation of antibiotics but no case of severe infection (severe sepsis or shock) or death occurred [13].…”

“…In addition, only few studies and 1 recent randomized trial have focused on neutropenic cancer patients [9,[11][12][13][14], but very limited data are currently available on the pre-engraftment period in HSCT. The safety of discontinuation of empirical treatment before the resolution of neutropenia has also been a source of debate [15,16]. The purpose of this study was to report the rates and outcomes of de-escalation (including discontinuation) during the pre-engraftment phase of allogeneic HSCT in patients with fever or infection and neutropenia.…”