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.