Is Less More? Antibiotic De-escalation in Hematopoietic Cell Transplants

• The conversation examines antimicrobial stewardship and its role in microbial resistance prevention and microbiome health in a broad transplant population.
• The panel explores when early antibiotic de-escalation may be safe and appropriate for patients undergoing hematopoietic cell transplantation in both adult and pediatrics.
• Experts discuss emerging evidence and guidelines supporting shorter courses of gram-negative and gram-positive antibiotic coverage in transplant recipients.

In a cobranded episode between Oncology On the Go, hosted by CancerNetwork^®, and the American Society for Transplantation and Cellular Therapy (ASTCT)’s program ASTCT Talks, an expert panel explored when early antibiotic de-escalation may be feasible for pediatric populations who undergo hematopoietic cell transplantation. The panel was hosted by Diego R. Hijano, MD, MSc, who was joined by his colleagues Gabriela Marón, MD, MSc, and Fareed Khawaja, MBBS.

Marón began by contextualizing the traditional practice of continuing antibiotic therapy until neutrophil recovery, which was based on host defense physiology instead of clinical trial data. Prolonged antibiotic use, she said, may correspond with resistant pathogens, bloodstream infections, and increased intensive care unit mortality across pediatric populations. Additionally, a limited pipeline for new antibiotic agents, especially for pediatric patients, makes the prevention of resistance critical during patient care.

Khawaja continued the discussion by highlighting recent literature and randomized clinical trials supporting the de-escalation of gram-negative coverage within 48 to 72 hours if no infection source is identified. He referenced new guidelines from the European Conference on Infections in Leukaemia, which support de-escalating antibiotics at 40 to 72 hours if no clear source of fever appears.¹ Another study published in 2023 showed that decreased antibiotic days resulted in similar rates of successful treatment, subsequent fever, and 30-day mortality.² Additionally, advances such as improved blood culture incubation and PET scans may bolster the ability of clinicians to safely de-escalate treatment.

Future directions in the field, Khawaja said, may include investigating how aggressive stewardship impacts long-term outcomes while learning how to implement quality improvement programs. Marón also identified a need for more prospective pediatric trials and data on how the microbiome changes following prolonged antibiotic exposure.

Hijano is medical director of Occupational Health and director of the Infectious Disease, Bone Marrow Transplant, and Cellular Therapy Division at St. Jude Children’s Research Hospital. Marón is a pediatric infectious disease specialist who works with patients who undergo transplant at St. Jude Children’s Research Hospital. Khawaja is an associate professor of Infectious Diseases, Infection Control and Employee Health, and Internal Medicine at The University of Texas MD Anderson Cancer Center.

References

1. Averbuch D, Vanbiervliet Y, Baccelli F, et al. Empirical and targeted antimicrobial therapy in patients with febrile neutropenia and haematological malignancy or after haematopoietic cell transplantation: recommendations from the 10th European Conference on Infections in Leukaemia. Lancet Infect Dis. 2026;26(6):e232-e247. doi: 10.1016/S1473-3099(25)00619-X.
2. Patel PA, Teherani MF, Xiang Y, et al. Short-course empiric antibiotics in children undergoing allogeneic hematopoietic cell transplantation. Transplant Cell Ther. 2023;29(12):778.e1-778.e6. doi:10.1016/j.jtct.2023.09.011