Introduction
The overuse of antimicrobials, the emergence of antimicrobial resistance worldwide, and increasing health-care associated costs have shown the importance of maximizing the application of antibiotic stewardship programs (ASP) in order to maintain the efficacy of currently existing antibiotics along with substantial cost savings.1,2This issue is particularly important when it comes to children with cancer, who frequently require antibiotics during periods of febrile neutropenia (FN) associated with the administration of cytotoxic chemotherapy or with their underlying disease.3,4 FN is a condition where evidence-based antibiotic prescribing is not frequently followed, as shown by a retrospective cohort study of audits performed during an ASP.1
In pediatric hematology-oncology (PHO) units, evidence-based use of antibiotics and antibiotic de-escalation strategies have the potential to decrease unnecessarily prolonged use of broad-spectrum antimicrobial agents,5 but such measures have not been studied extensively, especially on a national level.6 Studies in both adults and children have shown that in hematology-oncology units, antibiotic de-escalation and discontinuation can be safely implemented, i.e., without increasing the number of infectious deaths or Intensive Care Unit (ICU) admissions.7-10 For example, an open-label, randomized, controlled phase 4 clinical trial in six academic hospitals in Spain showed that in adults with hematological malignancies, high-risk FN and negative blood cultures, empirical antimicrobial therapy can be safely discontinued after 72 hours of apyrexia and clinical recovery irrespective of the absolute neutrophil count (ANC).11
In Greece, nearly 300 pediatric oncology patients aged 0 to 14 years are diagnosed annually, out of a national population of approximately 11 million people. Additionally, approximately 12 children with non-malignant diseases such as immunodeficiencies, homozygous beta-thalassemia, aplastic anemia, and other conditions require hematopoietic stem cell transplantation (HSCT) annually. Currently, there are six PHO units located in Greece: three units in Athens; two units in Thessaloniki, and one unit in Heraklion, Crete. In addition, there is a single pediatric bone marrow transplantation (BMT) unit located in Athens. The two PHO units in Thessaloniki and the PHO unit in Crete are in general university hospitals, while all units in Athens, including the BMT unit are in Aghia Sophia Children’s Hospital and P. and A. Kyriakou Children’s Hospital.
The Center for Clinical Epidemiology and Outcomes Research (CLEO) is an non-governmental, not-profit organization in Greece that surveils the most common hospital-acquired infections, with emphasis on improving prevention strategies and promoting and monitoring the judicious use of antibiotics.12 Since 2016, as part of the project Preventing Hospital Infections in Greece (PHIG), CLEO has been monitoring the use of antimicrobials in Greek PHO units with the goals of promoting the implementation of evidence-based insertion and maintenance bundles for central lines and encouraging implementation of international evidence-based guidelines for management of FN in children with cancer and HSCT recipients.13
The goal of this study is to describe the use of antibiotics in hospitalized children with cancer or children requiring HSCT in Greece and to evaluate the impact of a simple multifaceted intervention on prescribing practices. The results of PHIG intervention regarding central line-associated bloodstream infections will be the subject of a separate report.