Early identification of neutropenic patients at risk of grampositive bacteraemia and the impact of empirical administration of vancomycin

The aim of this multicentre randomised trial was to determine whether it was possible to predict gram-positive bacteraemia, and whether the empirical use of vancomycin would lead to reduced morbidity and mortality. 35 of 113 patients (31%; confidence interval, CI 8.5), who presented with a skin or soft tissue infection and had received empirical vancomycin in addition to either ceftazidime or piperacillin-tobramycin, had initial bacteraemia with a single gram-positive bacterium compared with 135 of the 784 (17%; CI 2.6), who presented with another infection and who had been givers ceftazidime or piperacillin-tobramycin without vancomycin (P<0.001). Empirical vancoanycin resulted in a higher rate of eradication (P=0.033, relative risk 1.2), but not a better clinical outcome and was associated with more toxicity (P=0.042, relative risk 1.6). Irrespective of the initial treatment regimen, fever lasted an average of 8 days, the empirical regimen was modified in more than 50% of cases and mortality attributed to gram-positive infection was less than 2%. Incorporating vancomycin in the initial empirical antibiotic regimen for febrile neutropenic patients does not appear necessary, even for skin and soft tissue infections associated with gram-positive bacteraemia. Copyright (C) 1996 Elsevier Science Ltd