The bone marrow transplant (BMT) antibiotic febrile neutropenia guidelines were updated in 2009. Due to national guidance on prudent prescribing of antimicrobials this is a priority for audit.1
Objective To assess whether choice and monitoring of antibiotics prescribed for febrile neutropenia follow Trust guidelines.
Methods A retrospective audit was conducted of consecutive patients admitted to the ward. Patients were included if they experienced an episode of febrile neutropenia. Prescribing was audited against the following standards; Standard One: patients prescribed piperacillin/tazobactam and gentamicin for their first febrile neutropenic episode. Patients with penicillin allergy or those with recent culture positive infection sensitive to agents other than piperacillin/tazobactam and gentamicin were excluded from this standard. Standard two Gentamicin trough level taken before second dose, then twice weekly (stat doses excluded). Standard three Vancomycin trough level taken at 24 h, then twice weekly (treatment less than 1 day excluded).
Results 17 of the 21 patients met the inclusion criteria. Standard one: 14 of the 17 patients received piperacillin/tazobactam plus gentamicin as first line therapy. Alternative antibiotics were prescribed due to penicillin allergy, renal impairment and microbiology advice. Therefore overall compliance with the standard was 88%. Standard two: 16 courses of gentamicin were prescribed. Trough levels were measured before the second dose for 15 courses (94%). For the nine courses that continued, trough levels were taken at least twice weekly. All levels were within range with the exception of one patient with renal impairment. Standard three: 12 patients received a course of vancomycin. A trough level was taken at 24 h for 10 patients (83%). Levels were monitored at least twice weekly for all patients who continued vancomycin, although 32% of all levels were subtherapeutic (<5 mg/l).
Conclusion The choice of initial antibiotics was generally in accordance with BMT guidelines. Alternative antibiotics were prescribed due to renal impairment and microbiology advice, which are reasonable exceptions. Gentamicin was monitored appropriately. Vancomycin dosing could be optimised as a third of levels were subtherapeutic, risking treatment failure and resistance. This will be disseminated to BMT consultants with a proposed review of vancomycin dosing.
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