Division of Infectious Diseases and Global Health, Department of Pediatrics, University of California, San Francisco.
Division of Infectious Diseases, Boston, Massachusetts.
J Pediatric Infect Dis Soc. 2020 Sep 17;9(4):428-436. doi: 10.1093/jpids/piz064.
Limited data exists regarding the effects of empiric antibiotic use in pediatric oncology patients with febrile neutropenia (FN) on the development of antibiotic resistance. We evaluated the impact of a change in our empiric FN guideline limiting vancomycin exposure on the development of vancomycin-resistant Enterococcus in pediatric oncology patients.
Retrospective, quasi-experimental, single-center study using interrupted timeseries analysis in oncology patients aged ≤18 years with at least 1 admission for FN between 2009 and 2015. Risk strata incorporated diagnosis, chemotherapy phase, Down syndrome, septic shock, and typhlitis. Microbiologic data and inpatient antibiotic use were obtained by chart review. Segmented Poisson regression was used to compare VRE incidence and antibiotic days of therapy (DOT) before and after the intervention.
We identified 285 patients with 697 FN episodes pre-intervention and 309 patients with 691 FN episodes postintervention. The proportion of high-risk episodes was similar in both periods (49% vs 48%). Empiric vancomycin DOT/1000 FN days decreased from 315 pre-intervention to 164 post-intervention (P < .01) in high-risk episodes and from 199 to 115 in standard risk episodes (P < .01). Incidence of VRE/1000 patient-days decreased significantly from 2.53 pre-intervention to 0.90 post-intervention (incidence rate ratio, 0.14; 95% confidence interval, 0.04-0.47; P = .002).
A FN guideline limiting empiric vancomycin exposure was associated with a decreased incidence of VRE among pediatric oncology patients. Antimicrobial stewardship interventions are feasible in immunocompromised patients and can impact antibiotic resistance.
在患有发热性中性粒细胞减少症（FN）的儿科肿瘤患者中，经验性使用抗生素对抗生素耐药性的发展影响的数据有限。我们评估了改变我们的经验性 FN 指南，限制万古霉素暴露对儿科肿瘤患者中万古霉素耐药肠球菌（VRE）发展的影响。
回顾性、准实验性、单中心研究，使用 2009 年至 2015 年间至少有 1 次 FN 住院治疗的≤18 岁肿瘤患者的中断时间序列分析。风险分层包括诊断、化疗阶段、唐氏综合征、感染性休克和 typhlitis。通过图表审查获得微生物学数据和住院抗生素使用情况。使用分段泊松回归比较干预前后 VRE 发生率和抗生素治疗天数（DOT）。
我们确定了 285 例患者有 697 例 FN 发作（干预前）和 309 例患者有 691 例 FN 发作（干预后）。两个时期高危发作的比例相似（49%比 48%）。高危发作时，经验性万古霉素 DOT/1000 FN 天数从干预前的 315 天减少到干预后的 164 天（P <.01），标准风险发作时从 199 天减少到 115 天（P <.01）。VRE/1000 患者天数的发生率从干预前的 2.53 显著下降到干预后的 0.90（发病率比，0.14；95%置信区间，0.04-0.47；P =.002）。
限制经验性万古霉素暴露的 FN 指南与儿科肿瘤患者中 VRE 的发生率降低相关。在免疫功能低下的患者中，抗菌药物管理干预是可行的，并且可以影响抗生素耐药性。
