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LETTER
Gram-Positive Infections and Quinolones in Neutropenia
Elio Castagnola, MD, and
Claudio Viscoli, MD
15 May 1997 | Volume 126 Issue 10 | Pages 830-831
TO THE EDITOR:
In their recent report, Bow and colleagues [1] suggest that prophylaxis with fluoroquinolones and rifampin in neutropenic patients decreases the incidence of gram-negative bacteremias and the overall number of documented infections. However, prophylaxis did not reduce the number of febrile episodes or the use of intravenous antibiotics and did not affect either the final outcome of febrile episodes that occurred despite prophylaxis or the overall mortality rate. Although the statistical power of the observed results is not clear (surprisingly, the manner in which the sample size was calculated was not explained), these results deserve some comments, especially about the conclusions one should draw from this article.
We wonder whether it is worthwhile to recommend widespread use of fluoroquinolone prophylaxis, with the accompanying risk for increasing resistance [2], in the absence of any pragmatic benefit for the patient receiving this prophylaxis. Moreover, because fluoroquinolone use may be associated with the emergence of bacteria that show cross-resistance to fluoroquinolones, ß-lactams, and aminoglycosides [3], we could face the risk for losing essential weapons for the treatment of febrile neutropenias. The authors themselves recognize that fluoroquinolone prophylaxis might increase the risk for infections from resistant microorganisms. A more reasonable approach might be to administer prophylaxis only to selected high-risk patients [4] or to narrow the target of prophylaxis, focusing on infections with specific pathogens [5].
In our opinion, the conclusion that should be drawn from Bow and colleagues' study is that fluoroquinolone prophylaxis with or without increased anti-gram-positive activity should not be recommended. This therapy has no pragmatic effect on the number of fevers or on the patient's final outcome and may increase antimicrobial resistance.
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Author and Article Information
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G. Gaslini Children's Hospital, 16147 Genova, Italy
National Institute for Cancer Research, University of Genova, Genova, Italy
1. Bow EJ, Mandell LA, Louie TJ, Feld R, Palmer M, Zee B, et al. Quinolone-based antibacterial chemoprophylaxis in neutropenic patients: effects of augmented gram-positive activity on infectious morbidity. Ann Intern Med. 1996; 125:183-90.
2. Cometta A, Calandra T, Bille J, Glauser MP.Escherichia coli resistant to fluoroquinolone prophylaxis in patients with cancer and neutropenia. N Engl J Med. 1994; 330:1240-1.
3. Richard P, Delangle MH, Merrien D, Barille S, Reynaud A, Minozzi C, et al. Fluoroquinolone use and fluoroquinolone resistance: is there an association? Clin Infect Dis. 1994; 19:54-9.
4. Viscoli C, Bruzzi P, Castagnola E, Boni L, Calandra T, Gaya H, et al. Factors associated with bacteremia in febrile granulocytopenic cancer patients. Eur J Cancer. 1994; 30:430-7.
5. Castagnola E, Lanino E, Garaventa A, Dini G, Dallorso S, Carrega G, et al. Prophylaxis of streptococcal bacteremia with oral penicillin V in children undergoing bone marrow transplantation. Support Care Cancer. 1995; 3:319-21.
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