Feasibility, efficacy, and adverse effects of outpatient antibacterial prophylaxis in children with acute myeloid leukemia

Authors

  • Hiroto Inaba MD, PhD,

    Corresponding author
    1. Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
    2. Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
    • Corresponding author: Hiroto Inaba, MD, PhD, Department of Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Mail Stop 260, Memphis, TN 38105-2794; Fax: (901) 521-9005; E-mail: hiroto.inaba@stjude.org

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  • Aditya H. Gaur MD,

    1. Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
    2. Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
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  • Xueyuan Cao PhD,

    1. Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
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  • Patricia M. Flynn MD,

    1. Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
    2. Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
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  • Stanley B. Pounds PhD,

    1. Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
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  • Viswatej Avutu BS,

    1. Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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  • Lindsay N. Marszal MA,

    1. Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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  • Scott C. Howard MD, MS,

    1. Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
    2. Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
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  • Ching-Hon Pui MD,

    1. Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
    2. Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
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  • Raul C. Ribeiro MD,

    1. Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
    2. Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
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  • Randall T. Hayden MD,

    1. Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee
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  • Jeffrey E. Rubnitz MD, PhD

    1. Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
    2. Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
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  • We thank Sharon Naron for editing the article.

Abstract

BACKGROUND

Intensive chemotherapy for pediatric acute myeloid leukemia incurs the risk of infectious complications, but the benefits of antibiotic prophylaxis remain unclear.

METHODS

In the current study, among 103 children treated on the AML02 protocol between October 2002 and October 2008 at St. Jude Children's Research Hospital, the authors retrospectively assessed the effect of antibiotic prophylaxis on the frequency of febrile neutropenia, clinically or microbiologically confirmed infections (including bacteremia), and antibiotic resistance, as well as on the results of nasal and rectal surveillance cultures. Initially, patients received no prophylaxis or oral cephalosporin (group A). The protocol was then amended to administer intravenous cefepime alone or intravenous vancomycin plus either oral cephalosporin, oral ciprofloxacin, or intravenous cefepime (group B).

RESULTS

There were 334 infectious episodes. Patients in group A had a significantly greater frequency of documented infections and bacteremia (both P < .0001) (including gram-positive and gram-negative bacteremia; P = .0003 and .001, respectively) compared with patients in group B, especially viridans streptococcal bacteremia (P = .001). The incidence of febrile neutropenia without documented infection was not found to be different between the 2 groups. Five cases of bacteremia with vancomycin-resistant enterococci (VRE) occurred in group B (vs none in group A), without related mortality. Two of these cases were preceded by positive VRE rectal surveillance cultures.

CONCLUSIONS

Outpatient intravenous antibiotic prophylaxis is feasible in children with acute myeloid leukemia and reduces the frequency of documented infection but not of febrile neutropenia. Despite the emergence of VRE bacteremia, the benefits favor antibiotic prophylaxis. Creative approaches to shorten the duration of prophylaxis and thereby minimize resistance should be explored. Cancer 2014;120:1985–1992. © 2014 American Cancer Society.

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