Advice from the Health Protection Agency

Guidance

The Health Protection Agency has provided the following advice about NICE's recommendation on reducing the risk of septic complications of anticancer treatment (see recommendation 1.2.1.1).

Fluoroquinolone prophylaxis is advocated as beneficial for some patients with neutropenia (see Antibiotic prophylaxis in neutropenic patients: new evidence, practical decisions). However, it raises 2 concerns:

fluoroquinolone prophylaxis can contribute to selection of resistance, particularly in Enterobacteriaceae
fluoroquinolones are associated with the selection of Clostridium difficile.

Attention should be paid to both risks.

Colonisation with resistant Enterobacteriaceae should be examined at induction of neutropenia and weekly thereafter until prophylaxis is stopped. The easiest method is to plate a rectal swab, or faeces, onto MacConkey agar, and to place a 1 mg (that is, standard) ciprofloxacin disc on the first series of streaks after the inoculum pool. After incubation the plate should be examined for bacterial colonies within the inhibition zone. If growth is found, the bacteria should be identified and their antibiograms determined, since many fluoroquinolone-resistant isolates are resistant to multiple other agents. The results should inform initial empiric therapy if the patient experiences a subsequent febrile episode. Time trends in resistance should be monitored, both in individual patients and within units.

Advice on the diagnosis of Clostridium difficile-related disease is provided in Updated guidance on the diagnosis and reporting of Clostridium difficile. This advice should be followed for patients with symptoms of diarrhoea.