β‐Lactam regimens for the febrile neutropenic patient

A total of 535 evaluable febrile episodes in neutropenic patients were randomly assigned to treatment with ticarcillin-clavnlanate plus vancomycin (TV), ceftazidime plus vancomycin (CV), or all three antibiotics (TCV). The TCV regimen was significantly more effective than TV, considering all evaluable episodes, documented infections, gram-negative infections, and infections in patients with persistent severe neutropenia (< 100 neutrophils/mm3). The results with CV were intermediate between TV and TCV. The toxicities were similar with all three regimens and consisted primarily of skin rashes. The TCV regimen is effective for empiric therapy of fever in neutropenic patients and probably should be utilized in preference to CV or TV, although its superiority over CV in this study was inconclusive. Cancer 659-16, 1990. HE INTRODUCTION OF P-LACTAM ANTIBIOTICS with T broad-spectrum activity against gram-negative bacilli has greatly improved the prognosis of infections in neutropenic patients. These antibiotics have been used successfully in combination with aminoglycosides for infections in neutropenic patient~.~-~ Several studies have shown that combinations of a cephalosporin plus a penicillin are at least as effective as one of these P-lactams plus an aminoglycoside.'-'' Indeed, in one study, the double P-lactam regimen was significantly superior for the treatment of gram-negative bacteremias and of infections in patients with persistent severe neutropenia." A few recent studies have indicated that a single P-lactam may represent adequate initial therapy for fever in neutropenic patients and that the addition of an aminoglycoside does not improve the response rate in gram-negative infections, although this remains a controversial i~sue.'~-'~ During the last decade there has been a resurgence of gram-positive infections in neutropenic patients, in part due to the widespread use of indwelling intravascular catheters.I6 Many of the p-lactam antibiotics with broadspectrum activity against gram-negative bacilli have only marginal activity against most of these gram-positive or