ASCO/IDSA Clinical Practice Guideline Update: Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression

As reported in the Journal of Clinical Oncology by Randy A. Taplitz, MD, of UC San Diego Health, and colleagues, ASCO and the Infectious Diseases Society of America (IDSA) have updated their joint guideline on antimicrobial prophylaxis for adult patients with immunosuppression associated with cancer and its treatment.

To update the guideline, an expert panel conducted a systematic review of relevant studies reported from May 2011 to November 2016, with six new or updated meta-analyses and six new primary studies adding to the evidence base. The expert panel was co-chaired by Dr. Taplitz and Christopher R. Flowers, MD, of Emory University School of Medicine.

Key recommendations are summarized/reproduced below.

Antibacterial Prophylaxis

  • Risk of febrile neutropenia (FN) should be systematically assessed (in consultation with infectious disease specialists as needed), including patient-, cancer-, and treatment-related factors.
  • Antibiotic prophylaxis with a fluoroquinolone is recommended for patients who are at high risk for FN or profound, protracted neutropenia (eg, most patients with acute myeloid leukemia/myelodysplastic syndromes [AML/MDS] or hematopoietic stem cell transplantation [HSCT] treated with myeloablative conditioning regimens). Antibiotic prophylaxis is not routinely recommended for patients with solid tumors.

Antifungal Prophylaxis

  • Antifungal prophylaxis with an oral triazole or parenteral echinocandin is recommended for patients who are at risk for profound, protracted neutropenia, such as most patients with AML/MDS or HSCT. Antifungal prophylaxis is not routinely recommended for patients with solid tumors. Additional distinctions between recommendations for invasive candidiasis and invasive mold infection are provided within the full text of the guideline.
  • Prophylaxis is recommended—eg, trimethoprim-sulfamethoxazole (TMP-SMX)—for patients receiving chemotherapy regimens associated with > 5% risk for pneumonia from Pneumocystis jirovecii (eg, those with ≥ 20 mg prednisone equivalents daily for ≥ 1 month or those on the basis of purine analogs).

Antiviral Prophylaxis

  • Herpes simplex virus–seropositive patients undergoing allogeneic HSCT or leukemia induction therapy should receive prophylaxis with a nucleoside analogue (eg, acyclovir).
  • Treatment with a nucleoside reverse transcription inhibitor (eg, entecavir or tenofovir) is recommended for patients who are at high risk of hepatitis B virus reactivation.
  • Yearly influenza vaccination with inactivated vaccine is recommended for all patients receiving chemotherapy for malignancy and all family and household contacts and health-care providers.
  • The expert panel also supports other vaccination recommendations for immunosuppressed adult oncology patients that are contained within the IDSA guideline for vaccination of the immunosuppressed host.

Additional Recommended Precautions

  • All health-care workers should comply with hand hygiene and respiratory hygiene/cough etiquette guidelines to reduce the risk for aerosol-based and direct or indirect contact–based transmission of pathogenic microorganisms in the health care setting.
  • Outpatients with neutropenia from cancer therapy should avoid prolonged contact with environments that have high concentrations of airborne fungal spores (eg, construction and demolition sites, intensive exposure to soil through gardening or digging, or household renovation).

Additional information is available at www.asco.org/supportive-care-guidelines.

The corresponding author for the Journal of Clinical Oncology article is ASCO; e-mail: guidelines@asco.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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