Prophylaxis of infection during chemotherapy-induced neutropenia in high-risk adults
- John R Wingard, MD
John R Wingard, MD
- Professor of Medicine
- University of Florida College of Medicine
Intensive cytotoxic chemotherapy can cause severe and sometimes prolonged neutropenia, which may result in hospitalization for treatment of fever or cause potentially fatal infection. Severe prolonged neutropenia is most likely to occur in the preengraftment phase of hematopoietic cell transplantation (HCT; particularly allogeneic) and in patients undergoing induction chemotherapy for acute leukemia. One approach to reducing infectious complications involves the use of prophylactic antibacterial, antiviral, and antifungal agents in patients at significant risk of such infections.
Because neutropenic patients are unable to mount robust inflammatory responses, serious infection can occur with minimal symptoms and signs. In such patients, fever is often the only sign of infection. Infections in neutropenic patients can progress rapidly, leading to hypotension and/or other life-threatening complications. Thus, empiric therapy with broad-spectrum antibiotics should be initiated promptly in all febrile neutropenic patients (including those receiving antimicrobial prophylaxis) to reduce the risk of serious morbidity and mortality. (See "Treatment of neutropenic fever syndromes in adults with hematologic malignancies and hematopoietic cell transplant recipients (high-risk patients)" and "Treatment and prevention of neutropenic fever syndromes in adult cancer patients at low risk for complications".)
The role of prophylactic antibacterial and antiviral agents in high-risk adults will be reviewed here. Infection control precautions for patients with chemotherapy-induced neutropenia will also be discussed. Related topic reviews regarding prophylaxis of infection in neutropenic patients include the following:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis 2011; 52:e56.
- US Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Common terminology criteria for adverse events (CTCAE). http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf (Accessed on February 16, 2012).
- Baden LR. Prophylactic antimicrobial agents and the importance of fitness. N Engl J Med 2005; 353:1052.
- Wingard JR, Eldjerou L, Leather H. Use of antibacterial prophylaxis in patients with chemotherapy-induced neutropenia. Curr Opin Hematol 2012; 19:21.
- Bow EJ. Fluoroquinolones, antimicrobial resistance and neutropenic cancer patients. Curr Opin Infect Dis 2011; 24:545.
- National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Prevention and treatment of cancer-related infections. Version 2.2014. http://www.nccn.org (Accessed on November 06, 2014).
- Ng ES, Liew Y, Koh LP, Hsu LY. Fluoroquinolone prophylaxis against febrile neutropenia in areas with high fluoroquinolone resistance--an Asian perspective. J Formos Med Assoc 2010; 109:624.
- Tomblyn M, Chiller T, Einsele H, et al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant 2009; 15:1143.
- Reduction of fever and streptococcal bacteremia in granulocytopenic patients with cancer. A trial of oral penicillin V or placebo combined with pefloxacin. International Antimicrobial Therapy Cooperative Group of the European Organization for Research and Treatment of Cancer. JAMA 1994; 272:1183.
- Bucaneve G, Micozzi A, Menichetti F, et al. Levofloxacin to prevent bacterial infection in patients with cancer and neutropenia. N Engl J Med 2005; 353:977.
- Rangaraj G, Granwehr BP, Jiang Y, et al. Perils of quinolone exposure in cancer patients: breakthrough bacteremia with multidrug-resistant organisms. Cancer 2010; 116:967.
- Gafter-Gvili A, Fraser A, Paul M, et al. Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy. Cochrane Database Syst Rev 2012; 1:CD004386.
- Leibovici L, Paul M, Cullen M, et al. Antibiotic prophylaxis in neutropenic patients: new evidence, practical decisions. Cancer 2006; 107:1743.
- Gafter-Gvili A, Paul M, Fraser A, Leibovici L. Effect of quinolone prophylaxis in afebrile neutropenic patients on microbial resistance: systematic review and meta-analysis. J Antimicrob Chemother 2007; 59:5.
- Eleutherakis-Papaiakovou E, Kostis E, Migkou M, et al. Prophylactic antibiotics for the prevention of neutropenic fever in patients undergoing autologous stem-cell transplantation: results of a single institution, randomized phase 2 trial. Am J Hematol 2010; 85:863.
- Cullen M, Steven N, Billingham L, et al. Antibacterial prophylaxis after chemotherapy for solid tumors and lymphomas. N Engl J Med 2005; 353:988.
- Saral R, Burns WH, Laskin OL, et al. Acyclovir prophylaxis of herpes-simplex-virus infections. N Engl J Med 1981; 305:63.
- Saral R, Ambinder RF, Burns WH, et al. Acyclovir prophylaxis against herpes simplex virus infection in patients with leukemia. A randomized, double-blind, placebo-controlled study. Ann Intern Med 1983; 99:773.
- Boeckh M, Kim HW, Flowers ME, et al. Long-term acyclovir for prevention of varicella zoster virus disease after allogeneic hematopoietic cell transplantation--a randomized double-blind placebo-controlled study. Blood 2006; 107:1800.
- Lubel JS, Angus PW. Hepatitis B reactivation in patients receiving cytotoxic chemotherapy: diagnosis and management. J Gastroenterol Hepatol 2010; 25:864.
- Firpi RJ, Nelson DR. Viral hepatitis: manifestations and management strategy. Hematology Am Soc Hematol Educ Program 2006; :375.
- van Dalen EC, Mank A, Leclercq E, et al. Low bacterial diet versus control diet to prevent infection in cancer patients treated with chemotherapy causing episodes of neutropenia. Cochrane Database Syst Rev 2016; 4:CD006247.
- Sonbol MB, Firwana B, Diab M, et al. Evaluating the effect of neutropenic diet on infection and mortality rate in cancer patients: A meta-analysis. J Clin Oncol 2015; 33(supplement):abstract 9619.
- Trifilio S, Helenowski I, Giel M, et al. Questioning the role of a neutropenic diet following hematopoetic stem cell transplantation. Biol Blood Marrow Transplant 2012; 18:1385.
- Taur Y, Xavier JB, Lipuma L, et al. Intestinal domination and the risk of bacteremia in patients undergoing allogeneic hematopoietic stem cell transplantation. Clin Infect Dis 2012; 55:905.
- Risk of serious complications
- Antibacterial prophylaxis
- - Indications
- - Guidelines
- - Evidence
- High-risk patients
- Intermediate-risk patients
- Low-risk patients
- Antifungal prophylaxis
- PCP prophylaxis
- Antiviral prophylaxis
- - Influenza
- - HSV and VZV
- - CMV
- - Hepatitis B
- Colony stimulating factors
- Infection control and general precautions
- Neutropenic diet
- MANAGEMENT OF NEUTROPENIC FEVER
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Antibacterial prophylaxis
- Antifungal and antiviral prophylaxis
- Other measures