Antimicrobial Stewardship in Cancer Patients: The Time is Now
Authors: Samuel L. Aitken, Jerod L. Nagel, Lilian Abbo, William Alegria, Jason N. Barreto, Sanjeet Dadwal, Alison G. Freifeld, Rupali Jain, Steven A. Pergam, Frank P. Tverdek, Susan K. Seo, _ _
Journal: Journal of the National Comprehensive Cancer Network (2019)

A lthough the widespread use of antimicrobials has made modern cancer care possible, the increase in number of infections due to multidrug-resistant organisms and the dearth of effective agents to combat them has created a serious and pressing issue facing healthcare providers who care for patients with cancer.In 2017, The Joint Commission mandated that every hospital establish an antimicrobial stewardship program (ASP) to optimize anti-infective use and improve patient care. 1 This standard applies not only to general patient populations but also to immunocompromised patients, including those with cancer and undergoing transplantation.This commentary describes the rationale for antimicrobial stewardship in patients with cancer, the current state of antimicrobial stewardship in hematology/ oncology, and how healthcare providers caring for patients with cancer can collectively improve antimicrobial use. Benefits of Antibiotics and Adverse ConsequencesThe history of cancer therapy is closely entwined with antimicrobial use.Patients with cancer receive prolonged and varied courses of antimicrobial agents to either prevent or treat infection, but such exposure increases the likelihood of bacterial resistance emergence.Infections caused by antibiotic-resistant pathogens, such as fluoroquinolone-resistant streptococci, vancomycin-resistant Enterococcus, and multidrug-resistant gram-negative bacteria (including extended-spectrum b-lactamase-producing and carbapenem-resistant strains), in patients with cancer are increasingly common.This is of particular importance in patients with cancer because delays in adequate therapy are associated with significantly increased mortality. 2The problem of antimicrobial overuse extends beyond antibiotic resistance and encompasses fungal and viral resistance as well as Clostridioides difficile (formerly Clostridium difficile) infections.The role of the microbiome is just beginning to be understood as it relates to clinical outcomes for patients with cancer.A loss of microbiome diversity is linked to increased infections in patients with hematologic malignancy, increased risk of gastrointestinal graft-versus-host disease, and poor response to immune checkpoint inhibitors. 3Although there is still much to learn about the human microbiome and its interplay with antibiotics in patients with cancer, mounting evidence suggests that how we use antimicrobials may have effects that extend far beyond the immediate problems of infections, antimicrobial resistance, and directly observable toxicities. Current State of Antimicrobial Stewardship in Patients With CancerThe Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS) advocate for formalizing antimicrobial stewardship in all patient populations. 4A practical way to approach this is through the creation of a formal institutional ASP that is led by an infectious disease-trained physician or a clinical pharmacist who works with and educates staff involved in antimicrobial ordering, 772