Antibiotics for the prevention of febrile neutropenia

Febrile neutropenia causes significant morbidity and mortality in patients receiving antineoplastic chemotherapy. Antibiotic prophylaxis reduces the incidence of fever during chemotherapy, but its routine use remains controversial for patients at low risk of neutropenic infection. This article reviews recent research to clarify the issue.

Randomized controlled trials and meta-analyses demonstrate that antibiotic prophylaxis reduces the incidence of febrile neutropenia and infection-related mortality both in patients receiving high-dose chemotherapy and in those receiving moderately myelosuppressive chemotherapy for solid tumours. The evidence that antibiotic prophylaxis results in adverse patient outcomes, through colonization or infection with resistant microorganisms is limited and unconvincing. Retrospective reanalysis of trial data indicates that for patients on moderately myelosuppressive out-patient chemotherapy, the greatest risk of infection and the greatest prophylactic benefit is on the first cycle.

Current guidelines recommend that antibiotic prophylaxis is considered in all patients at high and intermediate risk of febrile neutropenia. Clinical evidence now also supports antibiotic prophylaxis for low-risk patients. The impact of antibiotic prophylaxis during cyclical out-patient chemotherapy on microbial resistance should be determined. The hypothesis that, for low-risk patients, prophylaxis should be targeted to first chemotherapy cycles to retain efficacy but limit antibiotic exposure should be tested.