What are the ASCO/IDSA guidelines for the use of antibiotic agents in neutropenic cancer patients?

Updated: Sep 16, 2018
  • Author: Alexandre Chan, PharmD, MPH, FCCP, BCPS (AQ-ID), BCOP; more...
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Answer

Answer

Recommendations are as follows:

  • Monotherapy with an antipseudomonal β-lactam agent, such as cefepime, a carbapenem (eg, meropenem or imipenem-cilastatin), or piperacillin-tazobactam
  • Other antimicrobials (eg, aminoglycosides, fluoroquinolones, vancomycin) may be added for management of complications (eg, hypotension, pneumonia) or if antimicrobial resistance is suspected or proven.
  • Vancomycin (or other agents active against aerobic gram-positive cocci) is not recommended as a standard part of the initial antibiotic regimen for fever and neutropenia; such agents should be considered for specific clinical indications, including suspected catheter-related infection, skin or soft-tissue infection, pneumonia, or hemodynamic instability.

Early addition of the following modifications to initial empirical therapy may be considered for patients at risk for infection with antibiotic-resistant organisms, particularly if the patient’s condition is unstable or if the patient has positive blood-culture results suspicious for resistant bacteria (consensus based; evidence quality: low;  strength of recommendation: strong):

  • MRSA - Vancomycin, linezolid, or (if there is no evidence of pneumonia) daptomycin
  • VRE - Llinezolid or daptomycin.○ESBLs: Consider early use of a carbapenem.
  • Extended-spectrum β-lactamase (ESBL)–producing gram-negative bacteria - Carbapenem
  • Carbapenemase-producing organisms, including  Klebsiella pneumoniae carbapenemase KPCs: Polymyxin-colistin or tigecycline, or a newer β-lactam with activity against resistant gram-negative organisms 

Patients should be observed for ≥ 4 hours before discharge. Patients with febrile neutropenia who are at low risk of medical complications, in whom fever is responding to inpatient IV empirical antibiotic treatment, and hwo remain clinically stable, are considered eligible for transition to an outpatient regimen.


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