Berger, Christoph

Kindli, Karin

Nadal, David

Niggli, Felix

RERO DOC Digital Library

SHORT REPORTChristoph Berger Æ Karin Kindli Æ Felix K. NiggliDavid NadalWithholding initial vancomycin in febrile neutropenia despiteimplanted cathetersReceived: 6 January 2004 / Accepted: 25 March 2004 / Published online: 13 May 2004 Springer-Verlag 2004Empirical initial meropenem monotherapy allowedwithholding of vancomycin in febrile neutropenic chil-dren with implanted central venous catheters.Cancer children with fever and neutropenia are athigh risk for bacterial infections and require promptantimicrobial therapy [3]. Since implanted central ve-nous catheters (ICVC) provide an additional risk forinfectious complications [6] and are increasingly usedin these children, we evaluated their impact on theneed to complement initial empirical carbapenemmonotherapy.During a 24-month period, we prospectively evalu-ated 41 cancer children aged 0.3 to 15.4 years (mean 5.9years; median 6.1 years) with ICVC (Port-a-Cath,Pharmacia, Du¨bendorf, Switzerland) manifesting 82episodes of fever (axillary temperature >38.5C once or>38.0C on >2 occasions within 12 h) and neutropenia(<500 neutrophils/ll). A total of 33 episodes occurredin 19 children with acute lymphatic leukaemia, 23 in sixwith acute myelogenous leukaemia, two in two withlymphoma, and 24 in 14 with solid tumours. Empiricaltreatment was started with meropenem (20 mg/kg tid).When fever and neutropenia persisted and cultures werenegative after 48 h, vancomycin (40 mg/kg per day) andafter another 48 h amphotericin B (0.6 to 1.2 mg/kg perday) was added. Antimicrobials were continued for 5days after defervescence or termination of neutropeniaand, if a pathogen was isolated, treatment was continuedfor 14 days according to susceptibility testing.Of 82 episodes, 23 (28%)were microbiologicallydocumented, including 18 bacteraemias, two urinarytract and three viral infections (Table 1), 28 (34%) wereclinically documented and 31 (38%) were unexplained.Bacteraemia was caused by gram-positive bacteria in 15(83%) episodes (Table 1); 14 (78%) of these isolateswere meropenem-susceptible, as were Escherichia coliand Citrobacter spp.isolated from urine. No invasivefungal infection was diagnosed. Neutropenic fever per-sisting >48 h demanded addition of vancomycin in 35(43%) episodes and after 96 h of amphotericin B in 12%(Table 1). Isolation of meropenem-resistant bacteriademanded vancomycin addition in four (5%) episodes.Since symptoms were not severe and patients did notdeteriorate, vancomycin was not given before 48 h, i.e.not before meropenem resistance of the isolate wasknown. Repeated isolation of the same species fromblood in three of four children suggested colonisation ofthe ICVC and its removal resulted in resolution of fever.Initial empirical meropenem monotherapy for febrileneutropenia in cancer children with ICVC was eﬀective.The incidence of bacteraemia (22% of episodes) wassimilar to that in previous reports of children [2, 4, 5].The high rate of gram-positive bacteraemias (83%) ex-tends the shift towards gram-positive infections [2, 3, 4]and may be inﬂuenced by the universal presence ofICVC. Although the catheter frequency in children inprevious studies ranged from 82% to 90% [2, 4], itsrelevance with respect to infections was not investigated.All meropenem-resistant bacteria isolated from blood(5% of episodes) were gram-positive, susceptible tovancomycin, and caused no life-threatening infections.Three of four resistant isolates grew from contaminatedICVC. Withholding vancomycin until the meropenemresistance of the isolate was known resulted in no dis-advantage for the patients. Such a procedure, optionalin recent recommendations [3], would allow a vanco-mycin restriction of up to 100% within the ﬁrst 48 h. Inour cohort this translates to a prevention of vancomycinexposure by 164 days. We added vancomycin after 48 hPresented in part at the 42nd Interscience Conference on Antimi-crobial Agents and Chemotherapy (ICAAC), September 27, 2002San Diego, CA (Abstract G-1459).C. Berger (&) Æ K. Kindli Æ D. NadalDivision of Infectious Diseases, University Childrens Hospital,Steinwiesstrasse 75, 8032 Zurich, SwitzerlandE-mail: Christoph.Berger@kispi.unizh.chTel.: +41-1-2667111Fax: +41-1-2667157F. K. NiggliDivision of Oncology, University Children’s Hospital, Zurich,SwitzerlandEur J Pediatr (2004) 163: 422–423DOI 10.1007/s00431-004-1461-6in 43% of episodes which is within the range of25%–50% reported in other paediatric studies [1, 2, 4].Although this study was non-comparative, the verylow proportion of meropenem-resistant isolates stilljustiﬁes our conclusion that vancomycin is initially notneeded in addition to empirical meropenem treatment infebrile neutropenic cancer children with ICVC. Admin-istration of vancomycin is to be added only followingisolation of meropenem-resistant bacteria or on demandby escalation guidelines.Acknowledgements This study was supported in part by Astra-Zeneca AG, Zug, Switzerland.References1. Cometta A, Calandra T, Gaya H, Zinner SH, de Bock R, DelFavero A, Bucaneve G, Crokaert F, Kern WV, Klastersky J,Langenaeken I, Micozzi A, Padmos A, Paesmans M, Viscoli C,Glauser MP (1996) Monotherapy with meropenem versuscombination therapy with ceftazidime plus amikacin as empirictherapy for fever in granulocytopenic patients with cancer. TheInternational Antimicrobial Therapy Cooperative Group of theEuropean Organization for Research and Treatment of Cancerand the Gruppo Italiano Malattie Ematologiche Malignedell’Adulto Infection Program. Antimicrob Agents Chemother40: 1108–11152. Fleischhack G, Hartmann C, Simon A, Wulﬀ B, Havers W,Marklein G, Hasan C, Bode U (2001) Meropenem versus ceft-azidime as empirical monotherapy in febrile neutropenia ofpaediatric patients with cancer. J Antimicrob Chemother 47:841–8533. Hughes WT, Armstrong D, Bodey GP, Bow EJ, Brown AE,Calandra T, Feld R, Pizzo PA, Rolston KV, Shenep JL, YoungLS (2002) 2002 guidelines for the use of antimicrobial agents inneutropenic patients with cancer. Clin Infect Dis 34: 730–7514. Riikonen P (1991) Imipenem compared with ceftazidime plusvancomycin as initial therapy for fever in neutropenic childrenwith cancer. Pediatr Infect Dis J 10: 918–9235. Rubin M, Hathorn JW, Marshall D, Gress J, Steinberg SM,Pizzo PA (1988) Gram-positive infections and the use ofvancomycin in 550 episodes of fever and neutropenia. Ann In-tern Med 108: 30–356. Tobiansky R, Lui K, Dalton DM, Shaw P, Martin H, Isaacs D(1997) Complications of central venous access devices in childrenwith and without cancer. J Paediatr Child Health 33: 509–514Table 1 Febrile neutropenicepisodes (n =82) in 41 cancerchildren during a 24-monthperiod. Episodes were classiﬁedas microbiologicallydocumented (including 18bacteraemias, two urinary tractand three viral infections),clinically documented (site ofinfection identiﬁed, noorganism isolated) andunexplained fever (infectionmost likely, no site or organismidentiﬁed)Episode N Meropenem-resistant EscalationPlusvancomycinPlusamphotericin BMicrobiologically documented 23 4 16 4Bacteraemia due to: 18 4/18Streptococcus mitis 0/5Staphylococcus epidermidis 2/4Escherichia coli 0/3Streptococcus oralis 0/2Staphylococcus aureus 0/1Staphylococcus hominis 0/1Stomatococcus mucilaginosus 1/1Bacillus cereus 0/1Clinically documented 28 10 3Unexplained fever 31 9 3Total 82 4 (5%) 35 (43%) 10 (12%)423

Withholding initial vancomycin in febrile neutropenia despite implanted catheters

http://doc.rero.ch/record/312181/files/431_2004_Article_1461.pdf

Withholding initial vancomycin in febrile neutropenia despite implanted catheters

Abstract

Similar works

Full text

Available Versions

RERO DOC Digital Library