Routine antibiotics in the febrile cancer patient - should immune checkpoint inhibitors affect our practice?

Patients with cancer often attend emergency departments, with the most common presenting complaint being fever. Many of these patients receive antibiotics to treat possible sepsis, particularly when they are receiving chemotherapy. Immune checkpoint inhibitors are a relatively new cancer treatment option, especially for tumour types such as melanoma, renal cell carcinoma and non-small cell lung cancer. There is increasing evidence that exposure to antibiotics blocks the therapeutic action of checkpoint inhibitors, reducing response rates, increasing disease progression and decreasing overall survival rates. The effect is most marked when antibiotics are given prior to the commencement of the checkpoint inhibitors. Emergency medicine prescribes a lot of courses of antibiotics to this group of patients. It is important for emergency physicians to be aware of this association and the potential for antibiotics to be worsening long-term patient outcomes. There are many causes of fevers in oncology patients, with only some patients experiencing bacterial sepsis when presenting to emergency departments. Research on how to determine who should and shouldn't receive antibiotics is needed, perhaps leading to risk stratification guidelines. It would be good in future to avoid unnecessary antibiotics in those patients who are eligible for immunotherapy.