%0 Journal Article
%T Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: ASCO and IDSA Clinical Practice Guideline Update Summary
%A Christopher R. Flowers
%A Erin B. Kennedy
%A R
%A y A. Taplitz
%J General Information | Journal of Oncology Practice
%D 2018
%R https://doi.org/10.1200/JOP.18.00366
%X Patients who undergo cytotoxic chemotherapy and hematopoietic stem cell transplantation are at risk for infection, particularly during the period of neutropenia.1 Neutrophils are critical to provide host defense against infection, particularly bacterial and fungal infection. The risk of infection increases with the depth and duration of neutropenia, and the greatest risk occurs in patients who experience profound, prolonged neutropenia after chemotherapy, which is most likely to occur in the period before engraftment during hematopoietic cell transplantation and after induction chemotherapy for acute leukemia.2 Fever can be an important indicator and is often the only sign or symptom of infection, although clinicians should also be mindful that patients who are severely or profoundly neutropenic may present with suspected infection in an afebrile, or even hypothermic, state. Prevention and appropriate management of febrile neutropenia are important, because the rate of major complications (eg, hypotension, acute renal, respiratory or heart failure) in the context of febrile neutropenia is approximately 25% to 30%, and mortality may reach 11%.3,4 In the setting of severe sepsis or septic shock, the hospital mortality rate may be as high as 50%.5 In addition to depth and duration of neutropenia, other factors that contribute to immunosuppression and/or risk of infection in this patient population include the following: impaired integrity of mucocutaneous barriers (eg, catheters, mucositis), the type of treatment or conditioning regimens, metabolic perturbations (eg, diabetes, uremia), the presence of immunomodulating viruses, the presence of graft-versus-host disease, and perturbation of the microbiome. Antimicrobial prophylaxis is an intervention that can reduce the risk of infection in immunosuppressed patients. However, because of drug-related adverse effects as well as concerns with antimicrobial resistance, cost considerations, and the physiologic importance to the host of maintenance of equilibrium in the diversity and density of the host microbiome, the decision to administer prophylaxis requires a balance of benefits versus harms. The previous version of this guideline recommended antibacterial and antifungal prophylaxis for higher-risk patients and recommended that there was not a high enough baseline risk of febrile neutropenia and infection-related mortality in lower-risk patients to warrant routine administration of these agents.6 This version of the guideline includes updated meta-analyses of antimicrobial interventions for the prevention of
%U http://ascopubs.org/doi/full/10.1200/JOP.18.00366