Bloodstream infections in febrile neutropenic patients at a tertiary cancer institute in South India: A timeline of clinical and microbial trends through the years

Abstract

Introduction:Febrile neutropenia (FN) is an oncological emergency. The choice of empiric therapy depends on the locally prevalent pathogens and their sensitivities, the sites of infection, and cost. The Infectious Diseases Society of America guidelines are being followed for the management of FN in India.Methods:This is a prospective observational study conducted at a tertiary care cancer centre from September 2012 to September 2014.Objectives:The objectives of this study were as follows: (1) To review the pattern of microbial flora, susceptibility pattern, and important clinical variables among bloodstream infections in febrile neutropenic patients with solid tumors and hematological malignancies. (2) As per the institutional protocol to periodically review the antibiotic policy and susceptibility pattern, and compare the findings with an earlier study done in our institute in 2010. This was a prospective study conducted from September 2012 to September 2014.Results:About 379 episodes of FN were documented among 300 patients. About 887 blood cultures were drawn. Of these, 137 (15%) isolates were cultured. Isolates having identical antibiograms obtained from a single patient during the same hospitalization were considered as one. Hence, 128 isolates were analyzed. About 74 (58%) cultures yielded Gram-negative bacilli, 51 (40%) were positive for Gram-positive cocci, and 3 (2%) grew fungi. Among Gram-negative organisms, Escherichia coli followed by Acinetobacter baumannii and Klebsiella pneumoniae accounted for 78% of the isolates. Among Gram-positive cocci, Staphylococcus species accounted for 84% of the isolates. We have noted a changing trend in the antibiotic sensitivity pattern over the years. Following the switch in empirical antibiotics, based on the results of the study done in 2010 (when the empirical antibiotics were ceftazidime + amikacin), the sensitivity to cefoperazone-sulbactam has plunged from about 80% to 60%%. Similar reduction in susceptibility was noted for piperacillin-tazobactam, imipenem, and meropenem. On the contrary, there was a marked increase in sensitivity to ceftazidime (50–76%). Based on these results, we have reverted to ceftazidime + amikacin as the empirical antibiotics.Conclusion:Every institute must have a regular revision of antibiotic policy based on periodic assessment of the clinical and microbiological profile in FN. This will combat antibiotic resistance.

Assessment of Antimicrobial Prescription Pattern among Paediatric Cancer Patients with Febrile Neutropenia

“…Again, in this study, children receiving meropenem as monotherapy or in combination with amikacin/vancomycin were sensitive to gramnegative pathogens which includes Escherichia coli and Klebsiella pneumonia. This was similar to a finding reported in an Indian adult study conducted by Babu et al, where imipenem and meropenem demonstrated more than 70% efficacy toward the gram-negative isolates [25]. The most commonly used antifungal agent in the present study was amphotericin B, sensitive towards non-Candida albicans and Aspergillus species, which was similar among 6% adult patients in a study conducted in the USA [26].…”

Prevalence, Predictors, and Mortality of Bloodstream Infections Due to Methicillin-Resistant Staphylococcus Aureus in Patients with Malignancy: Systemic Review and Meta-Analysis

“…In the speci c subgroup of patients with febrile neutropenia, a total of 1351 BSI isolates from eight studies saw a pooled MRSA rate of 2% (95% CI 1-5%) (30,31,33,35,36,39,45,49). Half of the studies were conducted in Europe (33,35,39,45), two studies in the Western Paci c (30,31), one in South-East Asia (36), and one in the Eastern Mediterranean (49).…”

Prevalence, predictors, and mortality of bloodstream infections due to methicillin-resistant Staphylococcus aureus in patients with malignancy: systemic review and meta-analysis

“…Among a subset of 23 studies that contained data on 3690 Gram-positive BSI cases, the MRSA isolation rate in Gram-positive bacteria was 10% (95% CI 6-14%) (5,13,(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(47)(48)(49). In 15 studies whose number of S. aureus was more than 10, the pooled prevalence of MRSA among S. aureus was 44% (95% CI 32-57%) (5,13,28,32,34,36,38,(41)(42)(43)(44)(45)(46)(47)(48).…”

“…Based on data from 16 studies on 8461 adult BSI isolates, the MRSA isolation rate among BSIs in adults was 4% (95% CI 3-6%) (5,13,28,31,32,35,36,38,39,41,(43)(44)(45)(46)(47)(48). Besides, ve studies reported data on 927 BSI isolates from children and the MRSA prevalence in this population was 2% (95% CI 0-5%) (30,33,37,42,49).…”

“…In the speci c subgroup of patients with febrile neutropenia, a total of 1351 BSI isolates from eight studies saw a pooled MRSA rate of 2% (95% CI 1-5%) (30,31,33,35,36,39,45,49). Half of the studies were conducted in Europe (33,35,39,45), two studies in the Western Paci c (30,31), one in South-East…”