Myelosuppressive Chemotherapy for Haematological Malignancies

Myelosuppressive Chemotherapy for Haematological Malignancies - Guideline for Antibacterial Prophylaxis in Adult Patients undergoing

Publication: 26/01/2015

Last review: 01/03/2018

Next review: 01/03/2021

Clinical Guideline

CURRENT

ID: 4005

Approved By: Improving Antimicrobial Prescribing Group

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for Antibacterial Prophylaxis in Adult Patients undergoing Myelosuppressive Chemotherapy for Haematological Malignancies

1. Summary table of routine recommendations
2. Background information
3. Specific antibacterial prophylaxis recommendations

1. Summary table of routine recommendations

Myelosuppressive chemotherapy for the following diagnoses§	Recommendation	Evidence level	Aim of prophylaxis	NNT	*MRSA risk or fluoroquinolone contra-indicated#**
Acute myeloid leukaemia	Levofloxacin 500mg 24-hourly	A	Reduce all cause mortality	33	Co-trimoxazole 960mg 12-hourly
Acute lymphoblastic leukaemia	Levofloxacin 500mg 24-hourly	A	Reduce all cause mortality	33	Co-trimoxazole 960mg 12-hourly
Allogeneic stem cell transplantation	Levofloxacin 500mg 24-hourly	A	Reduce all cause mortality	33	Co-trimoxazole 960mg 12-hourly
Autologous stem cell transplantation	Levofloxacin 500mg 24-hourly	A	Reduce all cause mortality	33	Co-trimoxazole 960mg 12-hourly
Lymphomas or myelomas receiving chemotherapy regimens that mandate continuous in-patient (or ambulatory care) monitoring throughout the neutropenic phase	Levofloxacin 500mg 24-hourly	A	Reduce all cause mortality	50	Co-trimoxazole 960mg 12-hourly
Other aetiologies on an individual case basis as adjudged by treating Haematology consultant.	Levofloxacin 500mg 24-hourly	N/A	Reduce all cause mortality	N/A	Co-trimoxazole 960mg 12-hourly

§ If unsure – please discuss with specific treating Haematology consultant / team.
*MRSA risk = “known” previous MRSA infection &/or colonisation
# If neither of these agents appropriate, then no such antibacterial prophylaxis is recommended.
If doubt re choice of agent, discuss with unit specialist consultant microbiologist.

2. Background information

The role of antibiotic prophylaxis in patients undergoing myelosuppressive therapy is now clearly established following meta-analyses of large randomised trials in Cochrane reviews.¹ The majority of patients included in the largest trials are those with haematological malignancies, specifically acute myeloid leukaemia and acute lymphoblastic leukaemia. Allogeneic stem cell transplant recipients are also proportionately well represented as are patients undergoing autologous stem cell transplants. Patients with lymphoma and solid tumours are not well represented but it is reasonable to extrapolate the data to patients with these diagnoses undergoing myelosuppressive chemotherapy.
The indications for quinolone prophylaxis specified in this document are consistent with current NICE recommendations.²

3. Specific antibacterial prophylaxis recommendations

The antibiotic prophylaxis of choice is:
Levofloxacin 500mg 24-hourly.

In patients with a history of sensitivity to quinolones, or if quinolone-associated side effects develop on prophylaxis (e.g. tendinitis) then an acceptable alternative is:
Co-trimoxazole (Trimethoprim-sulfamethoxazole, septrin®) 960mg 12-hourly.

Route: Oral if possible. If unable to swallow – e.g. due to severe mucositis, and no enteral access, then administer intravenously (same doses as above).

When to start and stop antibacterial prophylaxis
Start: when absolute neutrophil count (ANC) falls below 0.5 x 10⁹/L following chemotherapy
Stop: when ANC recovers to ≥ 0.5 x 10⁹/L.
In patients with prolonged neutropenia due to resistant disease consider stopping prophylaxis.§

Interrupt: when patients are started on broad spectrum antibiotics and
resume prophylaxis when the broad spectrum antibiotics are stopped

Prior MRSA
Patients with prior MRSA (infection or colonisation) should be given prophylaxis with Co-trimoxazole .

Drug interactions
Note that Levofloxacin may interact with ciclosporin, monitor levels if Levofloxacin is stopped or started in patients on ciclosporin e.g. bone marrow transplant patients.

All recommendations are Evidence level A

Provenance

Record:	4005
Objective:
Clinical condition:	Patients undergoing myelosuppressive chemotherapy for haematological malignancies
Target patient group:	Adults
Target professional group(s):	Secondary Care Doctors Pharmacists
Adapted from:

Evidence base

Gafter-Gvili A, Fraser A, Paul M, et al: Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy. Cochrane Database Syst Rev. 1:CD004386.:10.1002/14651858.CD004386.pub3., 2012

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

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