ANTIBIOTIC STRATEGY AFTER THE EMPIRIC PHASE IN PATIENTS TREATED FOR AHEMATOLOGICAL MALIGNANCY

Empiric broad-spectrum antibiotic therapy has become a generally accep ted strategy in the treatment of febrile neutropenic patients. Particu larly in patients with prolonged neutropenia, subsequent adaptation of such a regimen will be the rule rather than exception. Since there ar e no uniformly accepted guidelines for the modification of antibiotic therapy during the post-empiric phase, we assessed the impact of a set of rules that evolved during the first randomized trials. Evaluation of the clinician's compliance with these rules in 1951 febrile neutrop enic episodes was the subject of the present analysis. Treatment was m odified in 761 (39%) cases, and these changes were made according to t he rules in 76%. For 75% of the alterations in treatment during the ev ening and night shifts, no reasonable explanation was established, whi le 93% of the modifications during the normal working hours were made for objective reasons, The empiric regimen was more frequently changed in patients with a clinical focus of infection at the onset of fever than in patients who showed fever as the only symptom of a possible in fection. The perceived need for modification amounted to 69% in pulmon ary infections, to 51% in skin and soft-tissue infections, to 44% in p atients with abdominal complaints, and to 37% in upper respiratory tra ct infections. Glycopeptides constituted 22% of modifications, particu larly in patients with a central venous catheter, and systemically act ive antifungals were administered in 16% of cases. Especially inexperi enced clinicians tend to adjust antibiotic therapy, in spite of the fa ct that persistence of fever alone seldom reflects inadequate treatmen t when the clinical condition of the patient is stable or improving. O n the other hand, the development of subsequent infectious events emph asizes that a genuine need for modification does frequently exist.