Alegria William, Marini Bernard L, Gregg Kevin Sellery, Bixby Dale Lee, Perissinotti Anthony, Nagel Jerod
1Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, and.
2Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California; and.
J Natl Compr Canc Netw. 2022 Feb 4;20(3):245-252. doi: 10.6004/jnccn.2021.7054.
There is minimal data evaluating the safety of antibiotic de-escalation in patients with acute myeloid leukemia (AML) with fever and ongoing neutropenia. Therefore, this study evaluated antibiotic prescribing, infection-related outcomes, and patient outcomes of an antibiotic de-escalation initiative.
This pre-post quasiexperimental study included adult patients with AML hospitalized with febrile neutropenia. An antibiotic de-escalation guideline was implemented in January 2017, which promoted de-escalation or discontinuation of intravenous antipseudomonal β-lactams. The primary outcome assessment was the incidence of bacterial infection in a historical control group before guideline implementation compared with an intervention group after guideline implementation.
A total of 93 patients were included. Antibiotic de-escalation occurred more frequently in the intervention group (71.7% vs 7.5%; P<.001), which resulted in fewer days of therapy for intravenous antipseudomonal β-lactams (14 vs 25 days; P<.001). Thirty-day all-cause mortality and length of hospitalization were not different between groups. However, the intervention group had significantly fewer episodes of Clostridioides difficile colitis (5.7% vs 27.5%; P=.007).
Implementation of an antibiotic de-escalation guideline resulted in decreased use of intravenous antipseudomonal β-lactams and fewer episodes of C difficile colitis, without adversely impacting patient outcomes. Additional studies are needed, preferably in the form of randomized controlled trials, to confirm these results.
评估急性髓系白血病（AML）伴发热和持续性中性粒细胞减少患者抗生素降阶梯治疗安全性的数据极少。因此，本研究评估了抗生素降阶梯治疗方案中抗生素的处方情况、感染相关结局和患者结局。
这项前后对照的准实验研究纳入了因发热性中性粒细胞减少而住院的成年AML患者。2017年1月实施了抗生素降阶梯指南，该指南提倡降阶梯或停用静脉注射抗假单胞菌β-内酰胺类药物。主要结局评估是指南实施前的历史对照组与指南实施后的干预组中细菌感染的发生率。
共纳入93例患者。干预组抗生素降阶梯治疗更为频繁（71.7%对7.5%；P<0.001），这导致静脉注射抗假单胞菌β-内酰胺类药物的治疗天数减少（14天对25天；P<0.001）。两组间30天全因死亡率和住院时间无差异。然而，干预组艰难梭菌结肠炎发作明显较少（5.7%对27.5%；P=0.007）。
实施抗生素降阶梯指南导致静脉注射抗假单胞菌β-内酰胺类药物的使用减少，艰难梭菌结肠炎发作减少，且未对患者结局产生不利影响。需要进行更多研究，最好采用随机对照试验的形式，以证实这些结果。
