Evaluation of concomitant therapy with vancomycin in febrile neutropenic patients receiving amikacin plus cefoperazone or ceftazidime

This study was performed to evaluate two regimens for the initial treatment of febrile neutropenic patients with presumed infections. Results were evaluated for efficacy, safety, cost, and need for vancomycin. Eighty-five patients with 120 episodes of fever were randomized to receive ceftazidime and amikacin or cefoperazone and amikacin for presumed bacterial infection. Forty-three percent of cases had bacterial infections; 23% were bacteremic. Response (patients did not receive any other antibiotics) was 54% with ceftazidime-amikacin (FA) and 51% with cefoperazone-amikacin (CA). No patients died from bacterial infection. Adverse reactions and days with fever were similar for both treatment groups. Forty-nine patients received parenteral vancomycin but its use was indicated in only 13 patients (26%). Of the 13 patients, 7 had infected catheter sites, 4 had skin infections, and 2 had bacteremia with catheter sites of normal appearance. During the study, 1074 days of treatment were required; savings in drug cost of $16,851 would have been realized if only CA had been used. In addition to the issues of safety and efficacy, the expense of antibiotic treatment for the febrile neutropenic patient is a consideration. In this study, dramatic decreases in antibiotic expense without compromising safety and efficacy of therapy were demonstrated. Cefoperazone and amikacin were more cost-effective than ceftazidime and amikacin. Also, vancomycin was overprescribed; it was indicated only for infected catheter sites, skin infection, or positive blood cultures.