A Nationwide Survey for the Management of Neutropenic Fever in Korea 945 they prescribed acyclovir in cases of unspecified interstitial pneumonia or encephalitis accompanying a change in men- tal status. Colony stimulating factor and granulocyte transfusion CSF therapy was routinely administered at 21 sites (63.6%) under the following conditions; 1) when the ANC was <500/ μL in 15 sites (71.7%), 2) at a defined time after chemother- apy or HSCT regardless of ANC in 2 sites (9.5%), 3) depend- ing on regimen in 2 sites (9.5%), and 4) other reasons in 2 sites (9.5%). Granulocyte transfusion was used in 14 sites (42.4%) under the following conditions: 1) when refractory infection occurred despite optimal antimicrobial therapy and neutropenia per- sisted (10 sites, 71.4%), 2) 1) plus reversibility of neutrope- nia (2 sites, 14.3%), and 3) 1) plus localized infection (2 sites, 14.3%) Duration of antimicrobial therapy Most sites terminated antimicrobial therapy when recov- ery of neutropenia was coupled with the disappearance of fever (Table 6). Additionally, six sites (18.1%) reported that antibiotics were terminated regardless of ANC when signs and symptoms of infection disappeared. However, the afebrile period required to stop antibiotics varied from 2 days to 14 days. DISCUSSION In Korea, HSCT has been performed in more than 5,000 patients since it was first conducted in 1983. In 2006, approx- imately 1,300 patients received HSCT and this number is expected to continue to rise (personal communication with Korean Stem Cell Transplantation Nurses Association). How- ever, there is no nationwide database system currently avail- able for the collection and analysis of data. Therefore, it is difficult to establish a national consensus for the antimicro- bial treatment of neutropenic fever following HSCT and chemotherapy. In the late 90s, a survey entitled, ‘the appro- priateness of the therapeutic use of antibiotics in patients with neutropenic fever’ was conducted in Korea (6). That survey, however, only evaluated the antibiotics used empiri- cally for neutropenic fever at 15 hospitals and then simply compared the result with guidelines of other countries. In addition, the survey did not assess the practical policies com- prising the overall management of neutropenic fever. In 2003, efforts were made to establish a Korean guideline for the treatment of neutropenic fever by the Korean Society of Chemotherapy. However, an evidence-based guideline could not be established due to insufficient data studied within our country. Therefore, they had suggested a recommenda- tion based on already existing guidelines such as IDSA at that time. So, this study is the first nationwide attempt to survey the overall practical policies regarding the manage- ment of neutropenic fever at hematology units or HSCT centers in Korea. The results of this survey showed that oral fluoroquinolones are now widely used as prophylaxis in neutropenic patients. We found that 57.6% and 90.9% of patients who under- went chemotherapy and HSCT received antimicrobial pro- phylaxis, respectively. A recent meta-analysis found that fluoroquinolone prophylaxis reduced all-cause mortality in neutropenic patients with hematologic malignancy when compared to patients that did not receive antibiotic prophy- laxis (7). However, ciprofloxacin is known to be an indepen- dent risk factor for the acquisition of methicillin resistant Staphylococcus aureus (8), and it is also believed that it is con- tributing to an increase in fluoroquinolone resistance among Escherichia coli that has already been observed in Korea (9, 10). So, it is necessary to define criteria such as to whom give the oral prophylaxic antibiotics-e.g., patients who were sus- pected to have prolonged neutropenia for more than 7 days. Although recent meta-analyses have indicated that the use of antibiotic monotherapy (11, 12) or oral antibiotics is effective for patients with neutropenic fever at low risk (13, 14), the most commonly used empirical regimen for neu- tropenic fever is 3rd or 4th generation cephalosporin (cef- tazidime or cefepime) in combination with aminoglycosides. Monotherapy was conducted in only 20% of the sites and oral antibiotics were used in only 9.1% of the sites that res- ponded to this survey. This is probably because prophylactic oral antibiotics had already been administered to most patients, which might lead to the belief that oral antibiotics could not be administered to patients that developed fever. How- ever, the low cost of hospitalization in Korea compared with that of other countries, coupled with the emotional trait of patients and doctors’ desire to avoid ambulatory treatments at outpatient clinics may also play a role in the choice of IV antibiotics. Therefore, carefully designed studies are needed to specify the conditions under which outpatient therapy is an acceptable and perhaps preferred choice for neutropenic fever in our country. The results of this survey also showed that only 2 sites (6.2%) routinely used a glycopeptide at the beginning of empirical therapy. These results are similar to those of a multicenter study (15) that failed to demonstrate that the addition of empirical vancomycin was beneficial, as well as to the results of a recent meta-analysis, which con- cluded that it is safe to defer the use of glycopeptides until a resistant gram-positive organism is documented (16). As we knew that the criteria to define fever and measuring methods were diverse among the sites and even within a site, a future guideline should include practically applicable criteria which clearly state these points. In addition, it should be kept in mind that empirical antibiotics should be initiated regard- less of fever if signs or symptoms of infection are present (1).