Current issues in the treatment of resistant bloodstream infections

Bloodstream infections cause significant morbidity and mortality for patients with hematologic malignancy. Antimicrobial drugs are the most reliable currently available treatment for infection, but several issues must be considered before choosing the appropriate regimen. Practitioners must be aware of changes in patterns of microbial prevalence and in drug resistance. Current worldwide data indicate a shift to gram-positive pathogens, with coagulase-negative staphylococci being the most common, and enterococcal and viridans group streptococcal species becoming problematic. Antimicrobial resistance continues to rise among these species, and while current drugs and combinations of them are effective in most cases, successful therapy will require the development of new drugs for which resistance has not emerged. Examples of such drugs include the oxazolidinones and glycylcyclines. While antibiotics will continue to be essential treatment for most patients with fever and neutropenia, a judicious reduction of exposure to antimicrobial drugs and enhanced infection control measures are warranted in the face of increasing antimicrobial resistance (e.g., vancomycin-resistant enterococci). The standard of care for patients who develop fever while neutropenic is empiric, broad-spectrum antibiotics that are modified as needed until fever and infection subside. Several factors, including antibiotic resistance, must be considered in choosing the empiric regimen.