New Guidelines: Antimicrobial Prophylaxis for Cancer Patients

Roxanne Nelson, BSN, RN

September 18, 2018

Cancer patients face a high risk for infection when undergoing cytotoxic chemotherapy and hematopoietic stem cell transplant (HSCT), particularly during the period of neutropenia. In this high-risk population, antimicrobial prophylaxis can reduce the risk for infection.

However, because of drug-related adverse effects and concerns about antimicrobial resistance, as well as cost considerations and the physiologic importance of maintaining equilibrium in the diversity and density of the microbiome, the decision of whether or not to use these agents prophylactically requires balancing benefits and harms.

To provide guidance on this issue, the American Society of Clinical Oncology (ASCO) has updated its 2013 recommendations for antimicrobial prophylaxis for immunosuppressed adult cancer patients. This updated recommendation differs from the earlier one in that it represents a joint effort with the Infectious Diseases Society of America (IDSA).

The new, updated guidelines have been published in the Journal of Clinical Oncology.

The authors point out that in the previous version of this guideline, antibacterial and antifungal prophylaxis was recommended for higher-risk patients. For lower-risk patients, the baseline risk for febrile neutropenia and infection-related mortality was not high enough to warrant the routine administration.

This new version, however, includes updated meta-analyses of antimicrobial interventions for preventing the onset of febrile neutropenia. In this guideline, febrile neutropenia is defined as fever in neutropenic patients in which there is a single oral temperature measurement of ≥38.3° C (101° F) or a temperature of ≥38.0° C (100.4° F) sustained over a 1-hour period.

Neutropenia is defined as an absolute neutrophil count <1000/μL (equivalent to <1.0 × 109/L), severe neutropenia as absolute neutrophil count < 500/μL (equivalent to <0.5 × 109/L), and profound neutropenia as <100/μL (equivalent to <0.1 × 109/L). The period of neutropenia is considered protracted if it lasts for ≥7 days.

Key Recommendations

The primary antimicrobial prophylaxis recommendations are as follows:

  • Risk for febrile neutropenia should be systematically assessed, in consultation with infectious disease specialists as needed.

  • Prophylaxis with a fluoroquinolone is recommended for those at high risk for febrile neutropenia or profound, protracted neutropenia. This would include patients with acute myeloid leukemia/myelodysplastic syndromes (AML/MDS) or patients who have undergone HSCT treated with myeloablative conditioning regimens. Antibiotic prophylaxis is not routinely recommended for cancer patients with solid tumors.

  • Antifungal prophylaxis with an oral triazole or parenteral echinocandin is recommended for patients who are at risk for profound, protracted neutropenia. This would include most patients with AML/MDS or HSCT. It is not routinely recommended for patients with solid tumors.

  • Prophylaxis (eg, with trimethoprim-sulfamethoxazole) is recommended for patients receiving chemotherapy regimens associated with >3.5% risk for pneumonia from Pneumocystis jirovecii.

  • Patients who are seropositive for herpes simplex virus and who undergo allogeneic HSCT or leukemia induction therapy should receive prophylaxis with a nucleoside analogue.

  • Treatment with a nucleoside reverse transcription is recommended for patients who are at high risk for hepatitis B virus reactivation.

  • An annual influenza vaccination with inactivated vaccine is recommended for all chemotherapy patients and all family and household contacts and healthcare providers.

  • The expert panel also supports the vaccination recommendations for immunosuppressed adult oncology patients that are contained within the IDSA guideline for vaccination of the immunosuppressed host.

Several coauthors have disclosed relationships with industry, as noted in the original article.

J Clin Oncol. 2018;Sep 4:JCO1800374. Full text

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