Lucena Mariana, Gaffney Kelly J, Urban Theresa, Forbes Catherine, Srinivas Pavithra, Majhail Navneet S, Cober Eric, Mossad Sherif B, Rybicki Lisa, Hamilton Betty K
Incyte (United States).
Medical University of South Carolina.
Clin Hematol Int. 2024 Feb 22;6(1):59-66. doi: 10.46989/001c.94105. eCollection 2024.
Febrile neutropenia (FN) is an oncologic emergency frequently encountered in hematopoietic cell transplant (HCT) and chimeric antigen receptor (CAR) T-cell therapy patients, which requires immediate initiation of broad-spectrum antibiotics. Data regarding antibiotic de-escalation (DE) in neutropenic patients are limited, and guideline recommendations vary. A clinical protocol for antibiotic DE of broad-spectrum agents was implemented if patients were afebrile after 72 hours and had no clinical evidence of infection. The primary endpoint was the difference in the number of antibiotic therapy days between the pre-and post-DE protocol implementation group. Secondary endpoints included rates of subsequent bacteremia during index hospitalization, 30-day mortality, and hospital length of stay. Retrospective chart reviews were conducted to assess outcomes for patients who received allogeneic HCT, autologous HCT, or CAR T-cell therapy under the antibiotic de-escalation protocol (post-DE) compared to those who did not (pre-DE). The pre-DE group underwent HCT/CAR T-cell from February 2018 through September 2018 (n=64), and the post-DE group from February 2019 through September 2019 (n=67). The median duration of antibiotics was significantly lower in the post-DE group (6 days; range 3-60 days) compared to the pre-DE group (8 days; range 3-31 days) (p=0.034). There were no differences in any secondary endpoints. We conclude that antibiotic DE in neutropenic HCT or CAR T-cell therapy patients treated with broad-spectrum antibiotics for at least three days who are afebrile and without documented infection appears to be a safe and effective practice. Adopting it significantly reduces the number of days of antibiotics without compromising patient outcomes.
发热性中性粒细胞减少症（FN）是造血细胞移植（HCT）和嵌合抗原受体（CAR）T细胞治疗患者中经常遇到的肿瘤急症，需要立即开始使用广谱抗生素。关于中性粒细胞减少患者抗生素降阶梯（DE）的数据有限，指南建议也各不相同。如果患者在72小时后体温正常且没有感染的临床证据，则实施广谱抗生素的抗生素降阶梯临床方案。主要终点是DE方案实施前后组间抗生素治疗天数的差异。次要终点包括指数住院期间随后发生菌血症的发生率、30天死亡率和住院时间。进行回顾性病历审查，以评估在抗生素降阶梯方案（DE后）下接受异基因HCT、自体HCT或CAR T细胞治疗的患者与未接受该方案（DE前）的患者的结局。DE前组于2018年2月至2018年9月接受HCT/CAR T细胞治疗（n = 64），DE后组于2019年2月至2019年9月接受治疗（n = 67）。与DE前组（8天；范围3 - 31天）相比，DE后组抗生素使用的中位持续时间显著缩短（6天；范围3 - 60天）（p = 0.034）。任何次要终点均无差异。我们得出结论，对于接受广谱抗生素治疗至少三天、体温正常且无感染记录的中性粒细胞减少HCT或CAR T细胞治疗患者，抗生素降阶梯似乎是一种安全有效的做法。采用该方法可显著减少抗生素使用天数，且不影响患者结局。
