Empiric Linezolid May Be Ineffective for Vancomycin-Resistant Enterococcus After AlloHCT

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Patients with fever and neutropenia who had undergone allogeneic hematopoietic stem cell transplantation and experienced pre-engraftment bacteremia were assessed.
Patients with fever and neutropenia who had undergone allogeneic hematopoietic stem cell transplantation and experienced pre-engraftment bacteremia were assessed.

According to a study published in Biology of Blood and Marrow Transplantation, empiric linezolid for fever and neutropenia had no effect on 30-day mortality in vancomycin-resistant Enterococcus (VRE)-colonized patients after allogeneic hematopoietic stem cell transplantation (alloHCT), nor did it alter the duration or recurrence of VRE bloodstream infection.

To assess the effectiveness of empiric linezolid therapy, a team at the Memorial Sloan Kettering Cancer Center conducted a retrospective review of institutional data on all alloHCT recipients who were 18 years or older and had pre-engraftment VRE bacteremia between January 1, 2005, and December 31, 2014. The team compared all-cause mortality at 30 days in febrile, neutropenic patients who underwent alloHCT, stratified by whether the patients received empiric or directed VRE therapy.

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Of 1306 transplants performed, 33% (434/1306) were conducted in patients who were colonized by VRE. A total of 95 patients developed pre-engraftment VRE bacteremia, and 87% (83/95) were confirmed to be colonized by VRE. Of these cases, 31% (29/95) received empiric linezolid therapy, while 69% (66/95) received directed therapy. In the empiric VRE treatment group, 86% (25/29) developed bacteremia on the same day that the linezolid was initiated.

No significant differences were observed in median duration (2 vs 2 days, P =.39) or recurrence of bacteremia (10% [3/29] vs 8% [5/66], P =.65), 30-day all-cause mortality (3% [1/29] vs 6% [4/66], P =.62), or VRE-attributable mortality (3% [1/29] vs 2% [1/66], P =.55) between the patients undergoing empiric compared with directed therapy. No significant difference was observed in the probability of survival at 30 days in patients who received empiric compared with directed therapy (97% vs 94%, P =.62).

Based on these results, the authors “do not recommend empiric VRE therapy in colonized patients undergoing alloHCT with fever and neutropenia.”

Reference

1. Kamboj M, Cohen N, Huang Y-T, et al. Impact of empiric treatment for vancomycin-resistant Enterococcus (VRE) in colonized patients early after allogeneic hematopoietic stem cell transplantation [published online November 15, 2018]. Biol Blood Marrow Transplant. doi: 10.1016/j.bbmt.2018.11.008

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