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 |
Copyright© Leeds Teaching Hospitals NHS Trust 2018 |
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated. |
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 |
A |
Reduce all cause mortality |
33 |
Co-trimoxazole |
Acute lymphoblastic leukaemia |
Levofloxacin |
A |
Reduce all cause mortality |
33 |
Co-trimoxazole |
Allogeneic stem cell transplantation |
Levofloxacin |
A |
Reduce all cause mortality |
33 |
Co-trimoxazole |
Autologous stem cell transplantation |
Levofloxacin |
A |
Reduce all cause mortality |
33 |
Co-trimoxazole |
Lymphomas or myelomas receiving chemotherapy regimens that mandate continuous in-patient (or ambulatory care) monitoring throughout the neutropenic phase |
Levofloxacin |
A |
Reduce all cause mortality |
50 |
Co-trimoxazole |
Other aetiologies on an individual case basis as adjudged by treating Haematology consultant. |
Levofloxacin |
N/A |
Reduce all cause mortality |
N/A |
Co-trimoxazole |
§ 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
Equity and Diversity
The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.