Early antimicrobial prophylaxis in autologous stem cell transplant recipients: Conventional versus an absolute neutrophil count‐driven approach

• Published in: Transplant infectious disease Vol. 23; no. 4; pp. e13689 - n/a
• Main Authors: Horowitz, Justin G., Gawrys, Gerard W., Lee, Grace C., Ramirez, Brittney A., Elledge, Carole M., Shaughnessy, Paul J.
• Format: Journal Article
• Language: English
• Published: Denmark Wiley Subscription Services, Inc 01-08-2021; John Wiley and Sons Inc
• Subjects: absolute neutrophil count; Anti-Bacterial Agents - therapeutic use; Anti-Infective Agents; Antiinfectives and antibacterials; Antimicrobial agents; antimicrobial stewardship; Autografts; Comparative analysis; Discordance; Disease prevention; Female; Fever; hematopoietic stem cell transplant; Hematopoietic Stem Cell Transplantation - adverse effects; Hematopoietic stem cells; Humans; Infections; Intervention; Leukocytes (neutrophilic); Male; Neutropenia; Neutrophils; Original; Patients; Prophylaxis; Reduction; Retrospective Studies; Stem cell transplantation; Stem cells; Transplant Recipients; Transplantation; Transplants & implants; antimicrobial stewardship; absolute neutrophil count; prophylaxis; hematopoietic stem cell transplant
• ISSN: 1398-2273; 1399-3062; 1399-3062
• DOI: 10.1111/tid.13689

Background
Autologous hematopoietic stem cell transplantation (HSCT) recipients are at increased risk of developing life‐threatening infections. There is discordance in published recommendations for timing of pre‐ and post‐transplant antimicrobial prophylaxis in this patient population, and these recommendations are unsubstantiated by any published comparative analyses.
Methods
An observational, pre‐ and post‐intervention study of consecutive autologous HSCT recipients was conducted over a 2‐year period. In the pre‐intervention cohort, antimicrobial prophylaxis was initiated on the day prior to transplant. In the post‐intervention cohort, antimicrobials were initiated once absolute neutrophil count (ANC) reached ≤500 cells/mm3. The primary outcome assessed was frequency of febrile occurrences. Secondary outcomes included total days of prophylaxis, positive blood cultures, all‐cause mortality, Clostridioides difficile infection rates, and length of stay.
Results
A total of 208 patients were included in the final analysis, with 105 and 103 patients in the pre‐ and post‐intervention cohorts, respectively. The majority of patients included were male. Lower rates of fever occurrences were observed in the post‐intervention cohort (83% pre‐ vs. 69% post‐intervention; p = 0.019). A significant reduction in the mean antibacterial days per patient was identified (9.7 vs. 4.6 days; p < 0.001). Other than lower rates of febrile neutropenia in the post‐intervention cohort, no differences were identified in secondary outcomes. In multivariable analyses, ANC‐driven prophylaxis was independently associated with decreased febrile events.
Conclusions
Delaying prophylaxis until severe neutropenia was not associated with increased febrile events or other secondary clinical outcomes evaluated. This approach is associated with a significant reduction in antimicrobial exposure.