Cutaneous T-cell lymphomas may require an exception to the ABHH consensus regarding empiric vancomycin use in febrile neutropenia

Abstract

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Dear Editor,

We read with great interest the recently published guidelines "Management of febrile neutropenia: consensus of the Brazilian Association of Hematology, Hemotherapy and Cell Therapy - ABHH" by Nucci et al. [1]. We fully support the overall recommendations, particularly the more conservative approach to the use of vancomycin as part of the empiric antibiotic regimen, which is well justified by recent epidemiological evidence [2, 3, 4, 5]. However, we would like to highlight a specific subgroup of patients who, in our view, should be considered an exception to the general recommendation against routine empirical anti-MRSA coverage: patients with advanced-stage cutaneous T-cell lymphomas (CTCL), particularly those with Sézary syndrome or extensive mycosis fungoides.

As noted in several studies, these patients have a significantly higher risk of skin and bloodstream infections caused by Staphylococcus aureus, including methicillin-resistant strains (MRSA) with this being one of the main causes of death [6, 7, 8]. The combination of profound immune dysregulation, extensive skin barrier disruption, and frequent colonization with S. aureus places these patients at a distinctively high risk of infections, which may progress rapidly to sepsis and death [9,10]. Additionally, the epidemiological studies cited in the guidelines to support the recommendation against empirical anti-MRSA coverage do not include a sufficient representation of patients with CTCL [2, 3, 4, 5], making it difficult to extrapolate findings for this population.

Given these considerations, we suggest that advanced-stage mycosis fungoides and Sézary syndrome patients should be explicitly recognized as a subgroup that may warrant empirical anti-MRSA coverage in cases of febrile neutropenia until further studies focusing on this specific population bring additional valuable information to optimize their management.

Author Contribution

Yung Gonzaga conceived and wrote the paper. Jose A. Sanches wrote the paper.

Conflicts of interest

Yung Gonzaga received honoraria and speakers' fees from Takeda. Jose A. Sanches received honoraria and speakers' fees from Takeda.