BJH - volume 15, issue 8, december 2024
Y. Vanbiervliet MD, R. Aerts MD, K. Lagrou MD, PhD, PharmD, A. Verlinden MD, PhD, J. Maertens MD, PhD, A. Schauwvlieghe MD, PhD
Background: Febrile neutropenia (FN) is an important complication in high-risk haematological patients, occurring in 80–90% of cases. While rapid initiation of broad-spectrum antibiotics has improved FN-related mortality, the optimal duration of treatment remains controversial. Prolonged use of antibiotics not only leads to resistance and toxicity but also to increased mortality and GVHD in allogeneic stem cell transplantation recipients due to disruption of the microbiome. Different guidelines provide different recommendations, leading to inconsistent practice and the ECIL guidelines are not widely implemented.
Methods: A national survey was conducted in Belgium to assess current practices for the management of FN in high-risk haematological patients. The electronic survey, consisting of 40 questions, was distributed to haematology centres via the newsletter of the Belgian Society of Haematology in January 2023. Responses from seventeen large haematology centres, including university hospitals, were analysed.
Results: Prophylactic measures such as germ-free diets and fluoroquinolone use were common, with 13/17 centres implementing germ-free diets and 11/17 centres using fluoroquinolone prophylaxis. Empirical broad-spectrum antibiotic treatment (EBAT) was initiated as monotherapy in 15/17 centres, predominantly with piperacillin-tazobactam (8/17) or third-/fourth-generation cephalosporins (7/17). Escalation to broader-spectrum antibiotics was common when FN persisted, with 9/17 centres using this approach. De-escalation practices varied, with 12/17 centres de-escalating if the patient showed improvement despite a severe initial presentation. Withdrawal of EBAT before neutrophil recovery occurred in 15/17 centres in stable, afebrile patients.
Discussion: The survey revealed partial compliance with the ECIL guidelines, with variations in escalation and de-escalation practices. While most centres followed recommended empirical treatments, de-escalation and early cessation remain difficult. The findings highlight the need for further research to optimise antibiotic use, reduce associated risks and reduce healthcare costs.
Conclusions: Although Belgian centres show better adherence to ECIL guidelines compared to other regions, challenges remain in de-escalation and early cessation of EBAT. A multicentre randomised controlled trial is needed to establish the safety of shorter EBAT durations and to improve antimicrobial stewardship.
(BELG J HEMATOL 2024;15(8):307–12)
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