Early antimicrobial prophylaxis in autologous stem cell transplant recipients: Conventional versus an absolute neutrophil count‐driven approach

Abstract

Background: Autologous hematopoietic stem cell transplantation (HSCT) recipients are at increased risk of developing life-threatening infections. There is discordance in published recommendations for timing of pre-and post-transplant antimicrobial prophylaxis in this patient population, and these recommendations are unsubstantiated by any published comparative analyses.Methods: An observational, pre-and post-intervention study of consecutive autologous HSCT recipients was conducted over a 2-year period. In the pre-intervention cohort, antimicrobial prophylaxis was initiated on the day prior to transplant. In the post-intervention cohort, antimicrobials were initiated once absolute neutrophil count (ANC) reached ≤500 cells/mm 3 . The primary outcome assessed was frequency of febrile occurrences. Secondary outcomes included total days of prophylaxis, positive blood cultures, all-cause mortality, Clostridioides difficile infection rates, and length of stay.Results: A total of 208 patients were included in the final analysis, with 105 and 103 patients in the pre-and post-intervention cohorts, respectively. The majority of patients included were male. Lower rates of fever occurrences were observed in the post-intervention cohort (83% pre-vs. 69% post-intervention; p = 0.019). A significant reduction in the mean antibacterial days per patient was identified (9.7 vs. 4.6 days; p < 0.001). Other than lower rates of febrile neutropenia in the post-intervention cohort, no differences were identified in secondary outcomes. In multivariable analyses, ANC-driven prophylaxis was independently associated with decreased febrile events.Conclusions: Delaying prophylaxis until severe neutropenia was not associated with increased febrile events or other secondary clinical outcomes evaluated. This approach is associated with a significant reduction in antimicrobial exposure.This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Management of Complex Infections in Hemophagocytic Lymphohistiocytosis in Adults

“…There is some controversy regarding bacterial prophylaxis in patients with hematologic diseases. In a study of early antibiotic prophylaxis in autologous HSCT recipients, neutrophil count-driven prophylactic antibiotic therapy was independently associated with a reduction in febrile events and mean antimicrobial days [ 89 ]. In 2007, the European Conference on Infections in Leukemia (ECIL) panel recommended the use of fluoroquinolones (FQ) for antimicrobial prophylaxis in high-risk neutropenic patients with an expected duration of neutropenia of more than 7 days [ 90 ].…”