Editor’s Note: The normal immune function of the body is crucial in defending against invading pathogens and maintaining the stability of the internal environment. In recent years, our understanding of the characteristics of infection and the principles of diagnosis and treatment in immunocompromised patients has also been deepened. At the IDWeek 2023, Professor Murat Akova from Hacettepe University in Turkey delivered a presentation titled “Let it Go: When to Discontinue Antibiotics in Febrile Neutropenia”, and shared his insightful views in an interview with “Infectious Disease Frontline”(IDF).
Murat Akova, Professor
Hacettepe University, Turkey
IDF: Good morning, Dr It was a great talk and thank you for doing this interview with us. And for the first question, you’ve conducted extensive research in the field of infectious diseases, particularly in immunocompromised patients. Could you provide an overview of your recent work and how it’s contributing to our understanding of infections in this patient population?
Professor Murat Akova: Well, thank you very much for this question. I mean, I have been on the field of immunocompromised those for long years and over all these years, I mean, I have observed significant changes in the area. So the main shift was that from prolonged therapy to shorter therapy in those febrile and neutropenic cancer patients. And just along with that, the other factor which affects this type of therapy is that risk categorization of febrile and neutropenic patients. In all days, all febrile and neutropenic cancer patients were considered a single risk category. So we admit them to the hospital, gave them broad antimicrobial therapy, particularly anti-sodermonal therapy. And these antibiotics were given during the entire course of febrile and neutropenia. However, we know these days that the febrile and neutropenic cancer patients are not a single homologous population. There are high risk group of patients, there are low risk group of patients and intermediate risk group of patients. For example, in those low risk neutropenic patients which are solid organ cancer treatment and less intensive patients with less intensive chemotherapy, we usually treat them in the outpatient setting with oral antibiotics. If the patient is stable, can tolerate oral antimicrobial therapy, doesn’t have any comorbidity. And this is a very effective therapy. So those patients are not exposed, you know, highly resistant bacteria when they are going to be admitted to the hospital. On the other hand, in high -risk group of patients, we usually admit them to the hospital for the first, you know, 48, 72 hours until they get stabilized, give them broad spectrum empirical antimicrobial therapy, but we attempt to de-escalate once we have the diagnosis or the patient defervesse immediately and stable, then we can easily switch a narrower spectrum of antibiotic therapy or as I was mentioning in my talk, we can overall stop the therapy as well. So these are the changes and over years I have done several research, several randomized trials in that respect and I contributed several guidelines, particularly ECIL guidelines and the ESCMID guidelines on that respect.
IDF: Thank you and your presentation is titled, Let it Go, Once You Just Continue Antibiotics and Fatal Natural Panion. Put your back deeper into this topic and end. and explain the key factors and considerations that clinicians should keep in mind when deciding when to discontinue antibiotics in pediatric patients with ribaroma and panula.
Professor Murat Akova: Well, probably I have answered some part of this questions in the first question, but the basic message is that the shorter the antibiotic therapy, the better avoidance of the complications of the antimicrobial therapy. First of all, I mean, broad spectrum antibiotics have been shown clearly, particularly in those patients with allergenic stem cell transplantation might adversely affect the morbidity and mortality in long term because they cause changes in the microbiome and these changes may alter the course of the transplantation and may indeed cause a higher mortality. So the accumulating evidence indicate that the broad spectrum antibiotics should not continue until the recovery from neutropenia. You can stop them early. If your patient is stable, if the patient differs early, then you can stop the antibiotics and observe your patients through the entire course of febrile neutropenia. Well, on the other hand, there is a debate whether these patients should switch to oral fluoroquinolones as prophylaxis after stopping the therapy. Some centers prefer to continue fluoroquinolone prophylaxis just before the empirical antimicrobial therapy. But these days, there are data emerging saying that quinolone antibiotics might adversely affect mortality. So some centers stop the antibiotics early and do not give any more antibiotics, just observe patients. So I think it depends the local epidemiology, local experience, but the main message is that do not treat these patients with broad spectrum antibiotics indefinitely.
IDF: Thank you. And for the last question, you’ve been actively involved in the development of cancer’s consents position statements, such as the one of advancing the standardized reporting of infection events in immunocompromised patients. Are there standardized reporting practices that benefits both clinical practice and research in the context of infectious disease in immunocompromised patients?
Professor Murat Akova: Yeah, I mean, as I said, I have been involved in ESIL guidelines. This is a group of European experts with several countries, more than 30 countries, and several experts from those countries are involved. So ESIL has been producing guidelines since 2005. Those group of scientists convene every other year and then discuss different aspects of immunocompromised host. So I think these guidelines are mainly targeting the practicing physicians, those physicians, well, particularly junior physicians, they need some guidance when they are alone. So these guidance are just to give advice for these physicians as well. But on the other hand, of course, these guidelines are not suggesting that you should do this all the time, but it’s a simple guidance to give some idea, you know, reviewing the literature and trying to provide some rules of standards of treating the patients. But of course, there are going to be some exceptions all the time because there are differences in epidemiology, differences type of patients. But I think they are very useful for the practicing physicians. So I’m very happy to be able to contribute these guidelines.
