Skip to main content
PMC home page
Antimicrobial Agents and Chemotherapy logoLink to Antimicrobial Agents and Chemotherapy
. 1992 May;36(5):1062–1067. doi: 10.1128/aac.36.5.1062

Vancomycin is not an essential component of the initial empiric treatment regimen for febrile neutropenic patients receiving ceftazidime: a randomized prospective study.

R Ramphal 1, M Bolger 1, D J Oblon 1, R J Sherertz 1, J D Malone 1, K H Rand 1, M Gilliom 1, J W Shands Jr 1, B S Kramer 1
PMCID: PMC188836  PMID: 1510394

Abstract

The use of vancomycin as part of the initial antibiotic therapy of febrile neutropenic patients has become a controversial issue. Some studies support its incorporation in the initial regimen, and others suggest that vancomycin can be added later. We examined this issue in a prospective, randomized trial. We randomized 127 febrile neutropenic patients to receive either ceftazidime alone or ceftazidime plus vancomycin as the initial empiric antibiotic treatment. We added vancomycin to the ceftazidime arm of the study when fever persisted after 96 h of monotherapy, when new fever occurred after this time, or when a moderately ceftazidime-resistant gram-positive bacterium was isolated. Each of these regimens had similar initial response rates, similar durations of initial fever, similar frequencies of new fever during therapy, similar microbiological cure rates, similar superinfection rates, and similar survival rates. We observed more renal and cutaneous toxicities in patients receiving vancomycin and ceftazidime as initial therapy. We conclude that ceftazidime is appropriate as initial therapy for febrile neutropenic patients and that the addition of vancomycin is appropriate when fever persists after 4 days of monotherapy or when fever recurs following an initial response.

Full text

PDF

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Anaissie E. J., Fainstein V., Bodey G. P., Rolston K., Elting L., Kantarjian H., Cabanillas F., McCredie K. B. Randomized trial of beta-lactam regimens in febrile neutropenic cancer patients. Am J Med. 1988 Mar;84(3 Pt 2):581–589. doi: 10.1016/0002-9343(88)90140-4. [DOI] [PubMed] [Google Scholar]
  2. Del Favero A., Menichetti F., Guerciolini R., Bucaneve G., Baldelli F., Aversa F., Terenzi A., Davis S., Pauluzzi S. Prospective randomized clinical trial of teicoplanin for empiric combined antibiotic therapy in febrile, granulocytopenic acute leukemia patients. Antimicrob Agents Chemother. 1987 Jul;31(7):1126–1129. doi: 10.1128/aac.31.7.1126. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Fainstein V., Bodey G. P., Elting L., Bolivar R., Keating M. J., McCredie K. B., Valdivieso M. A randomized study of ceftazidime compared to ceftazidime and tobramycin for the treatment of infections in cancer patients. J Antimicrob Chemother. 1983 Jul;12 (Suppl A):101–110. doi: 10.1093/jac/12.suppl_a.101. [DOI] [PubMed] [Google Scholar]
  4. Granowetter L., Wells H., Lange B. J. Ceftazidime with or without vancomycin vs. cephalothin, carbenicillin and gentamicin as the initial therapy of the febrile neutropenic pediatric cancer patient. Pediatr Infect Dis J. 1988 Mar;7(3):165–170. doi: 10.1097/00006454-198803000-00006. [DOI] [PubMed] [Google Scholar]
  5. Johnson M. P., Ramphal R. Beta-lactam-resistant Enterobacter bacteremia in febrile neutropenic patients receiving monotherapy. J Infect Dis. 1990 Oct;162(4):981–983. doi: 10.1093/infdis/162.4.981. [DOI] [PubMed] [Google Scholar]
  6. Karp J. E., Dick J. D., Angelopulos C., Charache P., Green L., Burke P. J., Saral R. Empiric use of vancomycin during prolonged treatment-induced granulocytopenia. Randomized, double-blind, placebo-controlled clinical trial in patients with acute leukemia. Am J Med. 1986 Aug;81(2):237–242. doi: 10.1016/0002-9343(86)90257-3. [DOI] [PubMed] [Google Scholar]
  7. Kramer B. S., Ramphal R., Rand K. H. Randomized comparison between two ceftazidime-containing regimens and cephalothin-gentamicin-carbenicillin in febrile granulocytopenic cancer patients. Antimicrob Agents Chemother. 1986 Jul;30(1):64–68. doi: 10.1128/aac.30.1.64. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. McWhinney P. H., Gillespie S. H., Kibbler C. C., Hoffbrand A. V., Prentice H. G. Streptococcus mitis and ARDS in neutropenic patients. Lancet. 1991 Feb 16;337(8738):429–429. doi: 10.1016/0140-6736(91)91205-9. [DOI] [PubMed] [Google Scholar]
  9. Nováková I., Donnelly J. P., De Pauw B. Ceftazidime as monotherapy or combined with teicoplanin for initial empiric treatment of presumed bacteremia in febrile granulocytopenic patients. Antimicrob Agents Chemother. 1991 Apr;35(4):672–678. doi: 10.1128/aac.35.4.672. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Philippon A., Labia R., Jacoby G. Extended-spectrum beta-lactamases. Antimicrob Agents Chemother. 1989 Aug;33(8):1131–1136. doi: 10.1128/aac.33.8.1131. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Pizzo P. A., Hathorn J. W., Hiemenz J., Browne M., Commers J., Cotton D., Gress J., Longo D., Marshall D., McKnight J. A randomized trial comparing ceftazidime alone with combination antibiotic therapy in cancer patients with fever and neutropenia. N Engl J Med. 1986 Aug 28;315(9):552–558. doi: 10.1056/NEJM198608283150905. [DOI] [PubMed] [Google Scholar]
  12. Ramphal R., Kramer B. S., Rand K. H., Weiner R. S., Shands J. W., Jr Early results of a comparative trial of ceftazidime versus cephalothin, carbenicillin and gentamicin in the treatment of febrile granulocytopenic patients. J Antimicrob Chemother. 1983 Jul;12 (Suppl A):81–88. doi: 10.1093/jac/12.suppl_a.81. [DOI] [PubMed] [Google Scholar]
  13. Rubin M., Hathorn J. W., Marshall D., Gress J., Steinberg S. M., Pizzo P. A. Gram-positive infections and the use of vancomycin in 550 episodes of fever and neutropenia. Ann Intern Med. 1988 Jan;108(1):30–35. doi: 10.7326/0003-4819-108-1-30. [DOI] [PubMed] [Google Scholar]
  14. Sanders J. W., Powe N. R., Moore R. D. Ceftazidime monotherapy for empiric treatment of febrile neutropenic patients: a meta-analysis. J Infect Dis. 1991 Nov;164(5):907–916. doi: 10.1093/infdis/164.5.907. [DOI] [PubMed] [Google Scholar]
  15. Sculier J. P., Klastersky J. Significance of serum bactericidal activity in gram-negative bacillary bacteremia in patients with and without granulocytopenia. Am J Med. 1984 Mar;76(3):429–435. doi: 10.1016/0002-9343(84)90662-4. [DOI] [PubMed] [Google Scholar]
  16. Shenep J. L., Hughes W. T., Roberson P. K., Blankenship K. R., Baker D. K., Jr, Meyer W. H., Gigliotti F., Sixbey J. W., Santana V. M., Feldman S. Vancomycin, ticarcillin, and amikacin compared with ticarcillin-clavulanate and amikacin in the empirical treatment of febrile, neutropenic children with cancer. N Engl J Med. 1988 Oct 20;319(16):1053–1058. doi: 10.1056/NEJM198810203191604. [DOI] [PubMed] [Google Scholar]
  17. Viscoli C., Moroni C., Boni L., Bruzzi P., Comelli A., Dini G., Fabbri A., Secondo V., Terragna A. Ceftazidime plus amikacin versus ceftazidime plus vancomycin as empiric therapy in febrile neutropenic children with cancer. Rev Infect Dis. 1991 May-Jun;13(3):397–404. doi: 10.1093/clinids/13.3.397. [DOI] [PubMed] [Google Scholar]

Articles from Antimicrobial Agents and Chemotherapy are provided here courtesy of American Society for Microbiology (ASM)

RESOURCES