European guidelines for empirical antibacterial therapy for febrile neutropenic patients in the era of growing resistance: summary of the 2011 4th European Conference on Infections in Leukemia

TLDR

Increasing resistance and a limited new‑antibiotic arsenal, especially against Gram‑negative pathogens, make carefully designed antibiotic regimens and effective infection control essential for febrile neutropenic patients. The guidelines recommend an escalation strategy that avoids empirical carbapenems for low‑risk patients, and a de‑escalation strategy with broad‑spectrum antibiotics for high‑risk patients, based on local resistance patterns and patient risk factors, while emphasizing infection control and stewardship. Regimens are tailored to local resistance data and patient risk factors, with adjustments at 72–96 h guided by clinical and microbiological results, and antibiotic discontinuation considered after 72 h for stable, afebrile patients. The strategy aims to reduce collateral damage from antibiotic overuse and curb further resistance selection.

Abstract

Owing to increasing resistance and the limited arsenal of new antibiotics, especially against Gram-negative pathogens, carefully designed antibiotic regimens are obligatory for febrile neutropenic patients, along with effective infection control. The Expert Group of the 4th European Conference on Infections in Leukemia has developed guidelines for initial empirical therapy in febrile neutropenic patients, based on: i) the local resistance epidemiology; and ii) the patient’s risk factors for resistant bacteria and for a complicated clinical course. An ‘escalation’ approach, avoiding empirical carbapenems and combinations, should be employed in patients without particular risk factors. A ‘de-escalation’ approach, with initial broad-spectrum antibiotics or combinations, should be used only in those patients with: i) known prior colonization or infection with resistant pathogens; or ii) complicated presentation; or iii) in centers where resistant pathogens are prevalent at the onset of febrile neutropenia. In the latter case, infection control and antibiotic stewardship also need urgent review. Modification of the initial regimen at 72–96 h should be based on the patient’s clinical course and the microbiological results. Discontinuation of antibiotics after 72 h or later should be considered in neutropenic patients with fever of unknown origin who are hemodynamically stable since presentation and afebrile for at least 48 h, irrespective of neutrophil count and expected duration of neutropenia. This strategy aims to minimize the collateral damage associated with antibiotic overuse, and the further selection of resistance.