Table 2.
Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: 2019 recommendations by ASCO and IDSA (adapted from Taplitz et al., 2018).
| Type of prophylaxis | Population | Recommendation | Strength of recommendation | Period of prophylaxis |
|---|---|---|---|---|
| Antibacterial | Patients at high risk of febrile neutropenia or profound, protracted neutropenia1,2 | Fluoroquinolone as prophylaxis however serious concerns exist (see foot note)3 | Evidence quality: high; Strength of recommendation: moderate | During expected neutropenia |
| Antifungal | Patients at high risk of febrile neutropenia or profound, protracted neutropenia1,2,4 Patients with GVHD |
Oral triazole or parenteral echinocandin; a mold-active triazole when the risk of invasive aspergillosis is > 6% 5 | Evidence quality: intermediate; Strength of recommendation: moderate | During expected neutropenia |
| Antifungal | Patients receiving chemotherapy regimens associated with > 3.5% risk for pneumonia from Pneumocystis jirovecii6 | Prophylaxis with oral trimethoprim-sulfamethoxazole or alternatives (such as dapsone, aerosolized pentamidine, or atovaquone in case of hypersensitivity to sulfonamides or cotrimoxazole intolerance | Evidence quality: high; Strength of recommendation: strong | Until myeloid reconstitution or engraftment after stem-cell transplantation, particularly during post-engraftment severe immunosuppression |
| Antiviral | HSV-seropositive patients undergoing HSCT or leukemia induction therapy | Antiviral prophylaxis with a nucleoside analog (eg, acyclovir) | Evidence quality: high; Strength of recommendation: strong | Until recovery of the WBC count or resolution of mucositis, whichever occurs later; duration can be extended for persons with frequent recurrent HSV infections or those with GVHD, or can be continued as VZV prophylaxis for up to 1 year |
| Antiviral | Patients at substantial risk of reactivation of HBV infection6 | Treatment with a nucleoside reverse transcription inhibitor (eg, entecavir or tenofovir) | Evidence quality: intermediate; Strength of recommendation: moderate | |
| Antiviral | All persons treated with chemotherapy for malignancy and their family and household contacts7 | Inactivated influenza vaccine (patients, household contacts and health care providers) | Evidence quality: intermediate; Strength of recommendation: moderate | Annual immunization is recommended Optimal timing of vaccination for patients being treated for cancer is not established, but serologic responses may be best between chemotherapy cycles (>7 days after the last treatment or >2 weeks before initiation of chemotherapy) In HSCT recipients better response if vaccinated >6 months after transplantation |
| Antiviral | Immunosuppressed adult oncology patients | The ASCO Expert Panel also supports other vaccination recommendations for immunosuppressed adult oncology patients that are contained within the IDSA guideline for vaccination of the immunosuppressed host7 | Evidence quality: intermediate; Strength of recommendation: moderate | |
| Additional precautions to reduce the risk for aerosol-and direct or indirect contact–based transmission of pathogenic microorganisms | All health care workers | Health care workers should comply with hand hygiene and respiratory hygiene/cough etiquette guidelines | Evidence quality: intermediate; Strength of recommendation: strong | Not applicable |
| Additional recommended precautions | Outpatients with neutropenia from cancer therapy | Outpatients with neutropenia from cancer therapy should avoid prolonged contact with environments that contain high concentrations of airborne fungal spores7 | Evidence quality: intermediate; Strength of recommendation: strong | Not applicable |
| Precautions no longer recommended | Footwear exchange, protected environments, air filtration, respiratory or surgical masks, neutropenic diet, or nutritional supplements | Evidence of clinical benefit is lacking for these interventions, therefore they are no longer recommended | Evidence quality: strong; Strength of recommendation: strong | Not applicable |
1. Patients with AML/MDS or HSCT treated with myeloablative conditioning regimens, or during treatment of GVHD. Antibiotic prophylaxis is not routinely recommended for patients with solid tumors.
2. Antibacterial and antifungal prophylaxis would generally not be indicated when CSF prophylaxis effectively reduces the depth and duration of neutropenia.
3. On November 15, 2018, EMA finalised a review of serious, disabling and potentially permanent side effects with quinolone and fluoroquinolone antibiotics given by mouth, injection or inhalation. Among other restrictions recommended for this drug class, the committee stated that they should not be used for preventing traveller’s diarrhoea or recurring lower urinary tract infections or in the treatment of mild or moderate bacterial infections unless other antibacterial medicines commonly recommended for these infections cannot be used.
The authors of the current review express their serious concerns on the potential use of quinolones as antibacterial chemoprophylaxis in neutropenic patients.
4. Grade III or IV mucositis entails a great risk for invasive candidiasis.
5. Patients with AML/MDS or during treatment of GVHD.
6. Those with ≥ 20 mg prednisone equivalents daily for ≥ 1 month or those on the basis of purine analogs.
7. Live viral vaccines should not be administered during immunosuppression period.
8. Construction and demolition sites, intensive exposure to soil through gardening or digging, or household renovation.
AML/MDS; acute myeloid leukemia/myelodysplastic syndrome, ASCO; American Society of Clinical Oncology, CSF; colony stimulating factor, GVHD; Graft versus host disease, HSV; Herpes simplex virus, HBV; Hepatitis B virus, HSCT; Hematopoietic stem-cell transplantation, IDSA; Infectious Diseases Society of America, VZV; varicella-zoster virus.