This is not the most recent version of the article. View current version (18 JAN 2012)

Intervention Review

Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy

  1. Anat Gafter-Gvili1,*,
  2. Abigail Fraser2,
  3. Mical Paul3,
  4. Marianne D van de Wetering4,
  5. Leontien CM Kremer4,
  6. Leonard Leibovici1

Editorial Group: Cochrane Gynaecological Cancer Group

Published Online: 19 OCT 2005

Assessed as up-to-date: 27 SEP 2005

DOI: 10.1002/14651858.CD004386.pub2


How to Cite

Gafter-Gvili A, Fraser A, Paul M, van de Wetering MD, Kremer LCM, Leibovici L. Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD004386. DOI: 10.1002/14651858.CD004386.pub2.

Author Information

  1. 1

    Beilinson Campus, Rabin Medical Center, Department of Medicine E, Petah-Tiqva, Israel

  2. 2

    University of Bristol, Oakfield House, Department of Social Medicine, MRC Centre for Causal Analysis in Translational Epidemiology, Bristol, UK

  3. 3

    Rabin Medical Center, Infectious Diseases Unit and Department of Medicine E, Petah-Tikva, Israel

  4. 4

    Emma Children's Hospital / Academic Medical Center, Paediatric Oncology, Amsterdam, Netherlands

*Anat Gafter-Gvili, Department of Medicine E, Beilinson Campus, Rabin Medical Center, 39 Jabotinsky Street, Petah-Tiqva, 49100, Israel. gn44@bezeqint.net.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 19 OCT 2005

SEARCH

This is not the most recent version of the article. View current version (18 JAN 2012)

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary

Background

Bacterial infections are a major cause of morbidity and mortality in neutropenic patients following chemotherapy for malignancy. Trials have shown the efficacy of antibiotic prophylaxis in reducing the incidence of bacterial infections, but not in reducing mortality rates.

Objectives

This review aimed to evaluate whether antibiotic prophylaxis in afebrile neutropenic patients reduced mortality when compared to placebo or no intervention.

Search methods

Electronic searches on The Cochrane Cancer Network Register of Trials (2005), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to 2005) and EMBASE (1980 to 2005) and abstracts of conference proceedings; references of identified studies; the first author of each included trial was contacted.

Selection criteria

RCTs or quasi-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention, or another antibiotic to prevent bacterial infections in afebrile neutropenic patients.

Data collection and analysis

Two authors independently appraised the quality of each trial and extracted data from the included trials. Relative risks (RR) or average differences, with their 95% confidence intervals (CI) were estimated.

Main results

One-hundred and one trials (12,599 patients) performed between the years 1973 to 2005 met the inclusion criteria. Antibiotic prophylaxis significantly decreased the risk for death when compared with placebo or no intervention (RR 0.66 [95% CI 0.55 to 0.79]) (comparison 1.1). The authors estimated the number needed to treat (NNT) in order to prevent 1 death from all causes as 50 (95% CI 34 to 268).

Prophylaxis resulted in a significant decrease in the risk of infection-related death, RR 0.59 (95% CI 0.47 to 0.75) (comparison 2.1) and in the occurrence of fever, RR 0.77 (95% CI 0.74 to 0.81) (comparison 3.1). A reduction in mortality was also evident when the more recently conducted quinolone trials were analysed separately. Quinolone prophylaxis reduced the risk for all-cause mortality, RR 0.52 (95% CI, 0.37 to 0.74) (comparison 1.101).

Authors' conclusions

Our review demonstrated that prophylaxis significantly reduced all-cause mortality. The most significant reduction in mortality was observed in trials assessing prophylaxis with quinolones. The benefit demonstrated in our review outweighs harm, such as adverse effects, and development of resistance, since all-cause mortality is reduced. Since most trials in our review were of patients with haematologic cancer, prophylaxis, preferably with a quinolone, should be considered for these patients.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary

To review prophylactic (preventive) antibiotic therapy given to cancer patients after chemotherapy, and before development of fever, in order to prevent infections and reduce mortality (the number of deaths)

For patients receiving chemotherapy, there is an increased risk of infection mediated through neutropenia (low white blood cell count). This is a toxic reaction of chemotherapy on the bone marrow and causes a dangerous decrease in the protective white blood cells.

The first sign of infection may be fever with the accompanying risks of morbidity (illness) and mortality. Without preventive measures, 48% to 60% of cancer patients who become feverish have an established infection. Antibiotic prophylaxis (prevention) has previously been shown to reduce fever and infections. The authors question was - Does antibiotic prophylaxis save lives?

The study included 101 randomised controlled trials (RCTs) (12,599 patients) performed between the years 1973 to 2005. Antibiotic prophylaxis significantly decreased the risk of death from all causes by 34% when compared to no intervention. The authors estimate that the number of patients needed to be treated with antibiotics in order to prevent one death from all causes was 50. It also decreased the rate of death from infection, and the rate of development of fever. However, this antibiotic prophylaxis may be associated with unfavourable effects and may encourage new and more resistant infection.

Several limitations of the authors' analysis should be noted:
Most studies were limited to haematological cancer patients (mostly leukaemia). Most were conducted on hospitalized patients. Information on all cause mortality could not be obtained for all the studies. Many studies were dated.

The authors' conclusion is that following chemotherapy, patients with a low white blood count who receive preventive antibiotic treatment for bacterial infections show a decrease in mortality. They believe that prophylaxis, preferably with a quinolone antibiotic where resistance permits, should be recommended for routine use in these patients.