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CC BY 4.0 · Indian J Med Paediatr Oncol
DOI: 10.1055/s-0045-1809990
Original Article

Escalation and De-Escalation Strategy for Initiating Antibiotics in Patients with Pediatric Cancer: A Prospective Observational Study

Abhishek Charan   *
1   Department of Pediatric and Medical Oncology, Cancer Institute (W.I.A), Chennai, Tamil Nadu, India
,
Gargi Das    *
1   Department of Pediatric and Medical Oncology, Cancer Institute (W.I.A), Chennai, Tamil Nadu, India
,
Prasanth Srinivasan 
1   Department of Pediatric and Medical Oncology, Cancer Institute (W.I.A), Chennai, Tamil Nadu, India
,
Balaji Thiruvengadam Kothandan
1   Department of Pediatric and Medical Oncology, Cancer Institute (W.I.A), Chennai, Tamil Nadu, India
,
Varalakshmi Vijayakumar
2   Department of Microbiology, Cancer Institute (W.I.A), Chennai, Tamil Nadu, India
,
Venkatraman Radhakrishnan
1   Department of Pediatric and Medical Oncology, Cancer Institute (W.I.A), Chennai, Tamil Nadu, India
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Funding None.
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Abstract

Introduction

Febrile neutropenia is common in children with cancer. Optimizing antibiotic therapy is crucial to improve outcomes and prevent resistance. Timely escalation or de-escalation is essential for effective care. Escalation starts with narrow-spectrum antibiotics, broadening if needed. De-escalation begins with broad-spectrum antibiotics and narrows once the pathogen is identified or if the child is clinically stable with sterile cultures.

Objectives

This study aims to analyze the use of third-line antibiotics (colistin and tigecycline) in children with cancer and evaluate the effectiveness of de-escalation versus escalation strategies for antibiotic use.

Materials and Methods

A prospective cohort study was conducted in children with cancer who received third-line antibiotics from October 2021 to September 2022. Demographic and treatment details were collected from medical records to compare antibiotic usage between escalation and de-escalation, and to identify risk factors for mortality. Convenient sampling was used to enroll 101 fever episodes with third-line antibiotic use over 1 year.

Results

In patients with predominantly hematolymphoid malignancies, 101/797 antibiotic-use episodes involved administration of third-line antibiotics. Inotropes were used in 50% of episodes, and 9% required ventilatory support. Positive blood culture was noted in 10 episodes, with multidrug-resistant (MDR) bacteria in 9 episodes. Stool was colonized with MDR bacteria in 45% of cases. Stool culture did not correlate with blood culture or mortality. An escalation strategy of antibiotics was used in 93 episodes and de-escalation strategy was used in 8 episodes; 57% patients' treatment adhered to institute antibiotic guidelines. The median duration of antibiotic use was shorter in the de-escalation strategy (10 vs. 5.5 days, p = 0.001). Ten deaths occurred, with sepsis as the contributory cause. Ventilator use was significantly associated with mortality (odds ratio 13.2, 95% confidence interval: 2.6–66.2, p = 0.002). Antibiotic policy did not impact mortality, but it is noteworthy that all deaths occurred in patients in whom antibiotics were escalated.

Conclusion

This study emphasized the utility of antibiotic de-escalation policy and the importance of testing these policies in larger randomized studies for children with cancer to improve outcomes and optimize antibiotic management.

Keywords

child - neoplasms - sepsis

Data Availability Statement

The data sets generated and analyzed during the current study are available from the corresponding author upon reasonable request.


Authors' Contributions

All authors contributed to the study's conception and design. A.C. and V.R. conceptualized and designed the study and performed initial material preparation and data collection. Literature search, final data analysis, and interpretation were performed by A.C., G.D., and V.R. The first draft of the manuscript was written by G.D., A.C., and V.R., and all other authors (P.S., T.K.B., V.V.) reviewed and edited the manuscript. All authors read and approved the final manuscript.


Patient's Consent

Patient consent was obtained from the patient.


* Abhishek Charan and Gargi Das have contributed equally to the paper and share first authorship.




Publikationsverlauf

Artikel online veröffentlicht:
03. Juli 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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