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Practice Guidelines
in Oncology – v.2.2009
Prevention and Treatment of
Cancer-Related Infections
Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09
Guidelines Index
Prevention/Treatment Infection TOC
Discussion, References
NCCN
®
Low
·
·
Standard chemotherapy
regimens for most solid tumors
Anticipated neutropenia less
than 7 d
Low
·
·
·
Bacterial - None
Fungal - None
Viral - None unless prior HSV episode
Intermediate
·
·
·
·
·
·
Autologous HSCT
Lymphoma
Multiple myeloma
CLL
Purine analog therapy (ie,
fludarabine, clofarabine,
nelarabine, 2-CdA)
Anticipated neutropenia 7 to 10 d
Usually HIGH, but some
experts suggest modifications
depending on patient status.
Purine analogs, intermediate
risk when used as single
agents; when combined with
intensive chemotherapy
regimens, the risk converts to
high.
·
·
·
Bacterial - Consider fluoroquinolone
prophylaxis
Fungal - Consider fluconazole during
neutropenia and for anticipated mucositis
Viral - During neutropenia and at least 30 d
after HSCT
High
·
·
·
·
·
Allogeneic HSCT
Acute leukemia
Induction
Consolidation
Alemtuzumab therapy
GVHD treated with high dose
steroids
>
>
Anticipated neutropenia greater
than 10 d
·
·
·
Bacterial - Consider fluoroquinolone
prophylaxis
Fungal -
Viral - during neutropenia and at least 30 d
after HSCT
See INF-3
OVERALL
INFECTION RISK IN
CANCER PATIENTS
a
DISEASE / THERAPY EXAMPLES
b
FEVER & NEUTROPENIA RISK
CATEGORY
(See FEV-3)
ANTIMICROBIAL PROPHYLAXIS
c,d,e,f
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
a
b
c
d
Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to
chemotherapy, and intensity of immunosuppressive therapy.
Multiple immune deficits can co-exist in the same patient.
Pneumocystis prophylaxis .
for dosing, spectrum, and specific comments/cautions.
for dosing, spectrum, and specific comments/cautions.
for dosing, spectrum, and specific comments/cautions.
e
f
()
)
See INF-5
See Antibacterial Agents (FEV-A
See Antifungal Agents (FEV-B)
See Antiviral Agents (FEV-C)
KEY: 2-CdA = chlorodeoxyadenosine (cladribine), CLL = chronic lymphocytic leukemia, CMV = cytomegalovirus, GVHD = graft versus host disease,
HSCT = hematopoietic stem cell transplant, HSV = herpes simplex virus, VZV = varicella zoster virus.
Usually HIGH, but significant
variability exists related to
duration of neutropenia,
immunosuppressive agents,
and status of underlying
malignancy
INF-1
Not for Distribution
Practice Guidelines
in Oncology – v.2.2009
Prevention and Treatment of
Cancer-Related Infections
Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09
Guidelines Index
Prevention/Treatment Infection TOC
Discussion, References
NCCN
®
OVERALL INFECTION RISK
IN CANCER PATIENTS
a
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
INF-2
Low
Intermediate
High
DISEASE/THERAPY EXAMPLES
AN BACTERIAL PROPHYLAXISTI
d
a
g
Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to
chemotherapy, and intensity of immunosuppressive therapy.
Although data support levofloxacin prophylaxis for low- and intermediate-risk patients, the panel discourages this practice in low-risk patients (because of concerns
about antimicrobial resistance); however, it can be considered in intermediate-risk patients.
d
for dosing, spectrum, and specific comments/cautions.
See Antibacterial Agents (FEV-A)
·
·
·
·
·
·
Autologous HSCT
Anticipated neutropenia 7 to 10 d
Lymphoma
CLL
Multiple myeloma
Purine analog therapy
None
g
Consider fluoroquinolone
prophylaxis
or
None
g
Consider fluoroquinolone prophylaxis
·
·
·
Allogeneic HSCT (neutropenic)
Acute leukemia (neutropenic)
MDS (neutropenic)
Anticipated neutropenia greater than 10 d·
GVHD Penicillin and TMP/SMX
DURATION
·
·
Standard chemotherapy regimens for
m solid tumors
Anticipated neutropenia less than 7 d
ost
Alemtuzumab TMP/SMX
For a minimum of 2 mo after
alemtuzumab and until CD4
200 cells/mcL³
Not for Distribution
Practice Guidelines
in Oncology – v.2.2009
Prevention and Treatment of
Cancer-Related Infections
Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09
Guidelines Index
Prevention/Treatment Infection TOC
Discussion, References
NCCN
®
INF-3
OVERALL INFECTION
RISK IN CANCER
PATIENTS
a
AN L PROPHYLAXISTIFUNGA
e
DURATION
AML (neutropenic)
h
ALL
h
Autologous HSCT
DISEASE/THERAPY EXAMPLES
MDS (neutropenic)
Allogeneic HSCT
(neutropenic)
Significant GVHD
i
·
·
Posaconazole (category 1)
or
k
k
Voriconazole (category 2B)
or
Amphotericin B products (category 2B)
·
l
·
·
Fluconazole
k
or
Amphotericin B products (category 2B)
l
·
·
Fluconazole (category 1)
or
Micafungin (category1)
k
With mucositis
j
Without mucositis
Consider no prophylaxis (category 2B)
Consider one of the following:
Fluconazole (category 1)
Micafungin (category 1)
Voriconazole (category 2B)
Posaconazole (category 2B)
·
·
·
·
·
k
k
k
k
Itraconazole (category 2B)
· Amphotericin B products (category 2B)
l
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Continue during
neutropenia and for
at least 75 d after
transplant
Until resolution of
neutropenia
a
e
k
l
Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to
chemotherapy, and intensity of immunosuppressive therapy.
for dosing, spectrum, and specific comments/cautions.
Recommendations on antifungal prophylaxis in patients with acute leukemia apply to those receiving induction or re-induction chemotherapy.
Consider antifungal prophylaxis in all patients with GVHD receiving immunosuppressive therapy. See Antifungal Prophylaxis section of the Discussion.
Severe mucositis is a risk factor for candidemia in patients with hematologic malignancies and stem cell transplant recipients not receiving antifungal prophylaxis.
AItraconazole, voriconazole, and posaconazole are more potent inhibitors of hepatic cytochrome P450 3 4 isoenzymes than fluconazole and may significantly decrease
the clearance of vinca alkaloids.
A lipid formulation is generally preferred based on less toxicity.
h
i
j
See Antifungal Agents (FEV-B)
Consider one of the following:
Posaconazole (category 1)·
·
·
k
k
Voriconazole (category 2B)
Echinocandin (category 2B)
)· Amphotericin B products (category 2B
l
Intermediate
to
High
Until resolution of
significant GVHD
Not for Distribution
Practice Guidelines
in Oncology – v.2.2009
Prevention and Treatment of
Cancer-Related Infections
Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09
Guidelines Index
Prevention/Treatment Infection TOC
Discussion, References
NCCN
®
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
INF-4
a
f
Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to
chemotherapy, and intensity of immunosuppressive therapy.
dosing,for spectrum, and specific comments/cautions.
Among allogeneic HSCT, there is more experience with acyclovir and valacyclovir than famciclovir.
Agents used as HSV prophylaxis are also active against VZV ( ).
m
n
See Antiviral Agents (FEV-C
See FEV-C
)
KEY: 2-CdA = chlorodeoxyadenosine (cladribine), CLL = chronic lymphocytic leukemia, CMV = cytomegalovirus, GVHD = graft versus host disease,
HSCT = hematopoietic stem cell transplant, HSV = herpes simplex virus, VZV = varicella zoster virus.
OVERALL
INFECTION RISK IN
CANCER PATIENTS
a
DISEASE / THERAPY
EXAMPLES
HERPES
VIRUSES
ANTIVIRAL
PROPHYLAXIS
DURATION OF ANTIVIRAL PROPHYLAXIS
f
Intermediate
·
·
·
·
·
Autologous HSCT
Lymphoma
Multiple Myeloma
CLL
Purine analog therapy
(ie, fludarabine)
Low
· Standard chemotherapy
regimens for solid tumors
· Acute leukemia
Induction
Consolidation
>
>
High
HSV
HSV
VZV
HSV
None unless prior
HSV episode
Acyclovir
Famciclovir
Valacyclovir
Acyclovir
Famciclovir
Valacyclovir
During neutropenia and at least 30 d after
HSCT
During neutropenia
HSV
VZV
· Alemtuzumab
therapy
Allogeneic HSCT·
Acyclovir
Famciclovir
or
Valacyclovir as
HSV prophylaxis
m
n
HSV prophylaxis
Minimum of 2 mo after alemtuzumab and
until CD4 200 cells/mcL
During neutropenia
n
·
³
· and at least 30 d after
HSCT
Pre-emptive therapy for CMV ( )
See INF-6
During neutropenia
CMV
(See INF-6) for CMV
Bortezomib
VZV
Acyclovir
Famciclovir
Valacyclovir
Not for Distribution
Practice Guidelines
in Oncology – v.2.2009
Prevention and Treatment of
Cancer-Related Infections
Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09
Guidelines Index
Prevention/Treatment Infection TOC
Discussion, References
NCCN
®
INFECTION RISK IN
CANCER PATIENTS
a
DISEASE / THERAPY EXAMPLES
AN
PROPHYLAXIS
TIPNEUMOCYSTIS
d
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
INF-5
High risk for
Pneumocystis jirovecii
(Pneumocystis carinii)
Allogeneic stem cell recipients (category 1)
Acute lymphocytic leukemia (category 1)
Consider (category 2B):
· Recipients of fludarabine and other T-cell
depleting agents
· Patients with neoplastic disease
receiving prolonged corticosteroids
or receiving temozolomide +
radiation therapy
o
p
· Autologous peripheral blood stem
cell transplant recipients
DURATION OF
PROPHYLAXIS
TMP/SMX (preferred)
or
Dapsone, aerosolized
pentamidine, or
aif
TMP/SMX intolerant
tovaquone
q
q
For at least 180 d
Throughout anti-leukemic
therapy
Until CD4 count is greater
than 200 cells/mcL
For a minimum of 2 mo after
alemtuzumab and until CD4
200 cells/mcL³
Alemtuzumab
3-6 mo after transplant
a
p
q
Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to
chemotherapy, and intensity of immunosuppressive therapy.
for dosing, spectrum, and specific comments/cautions.
Risk of PCP is related to the daily dose and duration of corticosteroid therapy. Prophylaxis against PCP can be considered in patients receiving the prednisone
equivalent of 20 mg or more daily for 4 or more weeks.
atovaquone
d
o
PCP prophylaxis should be used when temozolomide is administered concomitantly with radiation therapy and should be continued until recovery from
lymphocytopenia.
Consider trimethoprim/sulfamethoxazole desensitization or dapsone, aerosolized pentamidine, or when pneumonia prophylaxis is
required, and patients are trimethoprim/sulfamethoxazole intolerant.
Pneumocystis jirovecii
See Antibacterial Agents (FEV-A)
Not for Distribution
Practice Guidelines
in Oncology – v.2.2009
Prevention and Treatment of
Cancer-Related Infections
Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09
Guidelines Index
Prevention/Treatment Infection TOC
Discussion, References
NCCN
®
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
INF-6
PREVENTION OF CYTOMEGALOVIRUS DISEASE
INFECTION RISK IN
CANCER PATIENTS
a
DISEASE / THERAPY EXAMPLES
SURVEILLANCE PERIOD
r
High risk for
Cytomegalovirus
disease
Allogeneic stem cell
transplant recipients
Alemtuzumab
·
·
·
1 to 6 months after transplant
GVHD
CD4 < 100 cells/mcL
For a minimum of 2 mo after
alemtuzumab and until CD4
100 cells/mcL³
PRE-EMPTIVE THERAPY
f,s
Ganciclovir (IV)
or
Foscarnet (IV)
or
Valganciclovir (PO)
a
f
s
Categories of risk are based on several factors, including underlying malignancy, whether disease is in remission, duration of neutropenia, prior exposure to
chemotherapy, and intensity of immunosuppressive therapy.
for dosing, spectrum, and specific comments/cautions.
CMV surveillance consists of at least weekly monitoring of CMV by PCR or antigen testing.
Duration of prophylaxis antiviral therapy generally is for at least 2 weeks and until CMV is no longer detected.
r
See Antiviral Agents (FEV-C)
Not for Distribution
Practice Guidelines
in Oncology – v.2.2009
Prevention and Treatment of
Cancer-Related Infections
Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09
Guidelines Index
Prevention/Treatment Infection TOC
Discussion, References
NCCN
®
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Fever:
Neutropenia:
·
·
Single temperature
38.3°C orally or
38.0°C over 1 h
< 500 neutrophils/mcL
or
< 1,000 neutrophils/mcL
and a predicted decline
to 500/mcL over the
next 48 h
³
³
£
Site specific H&P including:
Supplementary historical information:
Others at home with similar symptoms
Pets
Travel
Tuberculosis exposure
Recent blood product administration
Laboratory/radiology assessment:
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
Intravascular access device
Skin
Lungs and sinus
Alimentary canal (mouth, pharynx, esophagus,
bowel, rectum)
Perivaginal/perirectal
Major comorbid illness
Time since last chemotherapy administration
History of prior documented infections
Recent antibiotic therapy/prophylaxis
Medications
HIV status
Exposures:
CBC including differential, platelets, BUN,
electrolytes, creatinine, and LFTs
Consider chest x-ray, urinalysis, pulse oximetry
Chest x-ray for all patients with respiratory
symptoms
>
>
>
>
>
See Initial
Therapy
FEV-2()
INITIAL EVALUATION OF FEVER AND NEUTROPENIA
FEV-1
CLINICAL PRESENTATION
·
·
Blood culture x 2 sets (one set
consists of 2 bottles). Options
include:
One peripheral + one catheter
or
Both peripheral
or
Both catheter
Diarrhea (
assay, enteric pathogen screen)
Viral cultures:
>
>
>
>
>
>
>
>
a
·
·
Urine (if symptoms, urinary
catheter, abnormal urinalysis)
Site-specific culture:
Skin (aspirate/biopsy of skin
lesions)
Vascular access cutaneous site
with inflammation (consider
routine/fungal/mycobacteria)
Clostridium difficile
Vesicular/ulcerated lesions on
skin or mucosa
Throat or nasopharynx for
respiratory virus symptoms,
especially during outbreaks
MICROBIOLOGIC
EVALUATION
a
Preferred for distinguishing catheter-related infections from secondary sources.
Not for Distribution
Practice Guidelines
in Oncology – v.2.2009
Prevention and Treatment of
Cancer-Related Infections
Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09
Guidelines Index
Prevention/Treatment Infection TOC
Discussion, References
NCCN
®
INITIAL THERAPY FOR FEVER AND NEUTROPENIA
b,c
·
·
·
Intravenous antibiotic monotherapy (choose one):
1
Cefepime (category 1)
Intravenous antibiotic combination therapy:
Aminoglycoside + antipseudomonal penicillin
(category 1) ± beta-lactamase inhibitor
(category 1)
Aminoglycoside + extended-spectrum
cephalosporin (cefepime, ceftazidime)
Oral antibiotic combination therapy for low risk
patients:
Ciprofloxacin + amoxicillin/clavulanate
(category 1) (for penicillin-allergic patients, may
use ciprofloxacin + clindamycin)
>
>
>
>
>
>
>
>
>
>
Imipenem/cilastatin (category 1)
Meropenem (category 1)
Piperacillin/tazobactam (category )
Ceftazidime (category 2B)
Ciprofloxacin + antipseudomonal penicillin
(category 1)
Use of vancomycin, linezolid, daptomycin or
quinupristin/dalfopristin is not routinely
recommended
d
f
g
h,i
e
>
Oral antibiotic regimen recommended should
not be used if quinolone prophylaxis was used
Mouth, Esophagus and Sinus/Nasal
(FEV-4)
Abdominal Pain, Perirectal Pain,
Diarrhea, Vascular Access Devices
(FEV-5)
Lung Infiltrates (FEV-6)
Cellulitis, Wound, Vesicular Lesions,
Disseminated Papules or other
lesions, Urinary Tract Symptoms,
Central Nervous System Symptoms
(FEV-7)
Follow-up (FEV-8)
OR
Initial antibiotic therapy should be
based on:
·
·
·
·
·
·
·
·
·
·
Infection risk assessment
()
Potential infecting organisms
include vancomycin-resistant
enterococcus (VRE) and
extended spectrum beta-
lactamase (ESBL)
Colonization with or prior
infection with methicillin-
resistant
(MRSA)
Site of infection
Local antibiotic susceptibility
patterns
Organ dysfunction/drug allergy
Broad spectrum of activity
Previous antibiotic therapy
Staphylococcus aureus
Antipseudomonal coverage
Bactericidal
See FEV-3
b
f
g
h
Consider local antibiotic susceptibility patterns when choosing empirical therapy. At hospitals where infections by antibiotic resistant bacteria (eg, MRSA or drug-
resistant gram-negative rods) are commonly observed, policies on initial empirical therapy of neutropenic fever may need to be tailored accordingly.
Weak Gram-positive coverage increased breakthrough infections limit utility.
Some authorities recommend avoidance of aminoglycosides because of potential nephrotoxicity, which may be diminished by once-daily administration. Once-a-day
aminoglycoside therapy should be avoided for treatment of meningitis or endocarditis.
c
e
for dosing, spectrum, and specific comments/cautions.
May interfere with galactomannan measurement.
Meta-analysis reported increased mortality associated with cefepime in randomized trials of neutropenic fever. However the FDA has concluded that cefepime remains
appropriate therapy for its approved indications based on the results of the FDA’s recent meta-analysis. (see Discussion).
and
Although there are published studies regarding the use of some of these agents in neutropenic patients, the NCCN panel strongly recommends that these agents
should not be routinely used as initial empirical therapy for neutropenic fever because of concerns about resistance and breakthrough infections.
d
i
See Antibacterial Agents (FEV-A
Agents
)
See Appropriate Use of Vancomycin and Other for Gram-positive Resistant Infections (FEV-D).
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
FEV-2
Site-Specific Evaluation and Therapy:
Not for Distribution
Practice Guidelines
in Oncology – v.2.2009
Prevention and Treatment of
Cancer-Related Infections
Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09
Guidelines Index
Prevention/Treatment Infection TOC
Discussion, References
NCCN
®
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
INITIAL RISK ASSESSMENT FOR FEBRILE NEUTROPENIC PATIENTS
j
Initial evaluation
Low-risk (none of the above factors and most of the following):
·
·
·
£
·
·
·
·
Outpatient status at time of development of fever
No associated acute comorbid illness, independently
indicating inpatient treatment or close observation
Good performance status (ECOG 0-1)
No hepatic insufficiency
No renal insufficiency
OR
A score of 21 or greater on the MASCC Risk Index
Anticipated short duration of severe neutropenia
( 100 cells/mcL for < 7 d)
j
SITE OF CARE TREATMENT OPTIONS
Hospital
OR
Consider ambulatory
clinic
OR
Home for selected
low-risk patients with
adequate outpatient
infrastructure
established
Hospital
Oral therapy
(category 1)
IV therapy
or
Sequential
IV/oral therapy
IV therapy
j
Risk categorization refers to risk of serious complications, including mortality, in patients with neutropenic fever. .
k
Uncontrolled/progressive cancer is defined as any leukemic patient not in complete remission, or non-leukemic patients with evidence of disease progression after
more than 2 courses of chemotherapy.
See Risk Assessment Resources (FEV-E)
See Outpatient
Therapy for
Low-Risk
Patients
FEV-13()
FEV-3
High-risk (any factor listed below):
·
·
·£³
·
·
·
·
·
·
·
Inpatient status at time of development of fever
Significant medical comorbidity or clinically unstable
Uncontrolled/progressive cancer
Pneumonia or other complex infections at clinical presentation
Alemtuzumab
Mucositis grade 3-4
OR
Anticipated prolonged severe neutropenia: 100 cells/mcL and 7 d
Hepatic insufficiency (5 times ULN for aminotransferases)
Renal insufficiency (a creatinine clearance of less than 30 mL/min)
MASCC Risk Index score of less than 21
k
j
Not for Distribution
Practice Guidelines
in Oncology – v.2.2009
Prevention and Treatment of
Cancer-Related Infections
Version 2.2009, © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.08/28/09
Guidelines Index
Prevention/Treatment Infection TOC
Discussion, References
NCCN
®
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Mouth/
mucosal
membrane
INITIAL CLINICAL
PRESENTATION
(DAY 0)
FINDING
Necrotizing
ulceration
·
·
Culture and gram stains
Viral -
Fungal
Consider leukemic infiltrate
>
>
Herpes simplex virus
(HSV)
Biopsy for lesions
suspicious for mold
>
EVALUATION ADDITIONS TO INITIAL EMPIRIC REGIMEN
c,l,m
·
·
·
Ensure adequate anaerobic activity
Consider anti-HSV therapy
Consider systemic antifungal therapy
Vesicular lesions
Viral cultures or PCR or
other diagnostics
and
direct fluorescent antibody
test for HSV and Varicella-
zoster virus (VZV)
Anti-HSV therapy (category 1)
Sinus/
nasal
·
·
·
·
Sinus tenderness
Periorbital cellulitis
Nasal ulceration
Unilateral eye tearing
·
·
·
High resolution sinus
CT/orbit MRI
ENT/ophthalmological
urgent evaluation
Culture and stains/biopsy
Esophagus
·
·
Retrosternal burning
Dysphagia/
odynophagia
·
·
·
·
Initial therapy guided by clinical findings
(eg, thrush or perioral HSV)
Antifungal therapy
Fluconazole, first-line therapy
Voriconazole, posaconazole, or
echinocandin if refractory to fluconazole
Acyclovir
If at high risk for invasive CMV, consider
ganciclovir or foscarnet
>
>
·
·
Add vancomycin if periorbital cellulitis noted
ious disease consult
Add lipid amphotericin B preparation to
cover possible aspergillosis and
mucormycosis in high risk patients with
suspicious CT/MRI findings
Infect
n
·
FEV-4
Thrush
·
·
·
Culture suspicious oral
lesions
HSV
Fungal
Consider endoscopy, if no
response to therapy
Consider CMV esophagitis
in patients at high risk for
CMV disease
>
>
See
Follow-up
FEV-8()
All febrile neutropenic patients should receive broad-spectrum antibiotics (FEV-2)
· Antifungal therapy
Fluconazole first-line therapy
Voriconazole, posaconazole, or
echinocandin if refractory to fluconazole
>
>
c
for dosing, spectrum, and specific comments/cautions.
for dosing, spectrum, and specific comments/cautions.
for dosing, spectrum, and specific comments/cautions.
l
m
n
Posaconazole can be considered for salvage therapy or for intolerance to amphotericin B formulations. Posaconazole is not approved by the FDA as either primary or
salvage therapy for invasive fungal infections.
See Antibacterial Agents (FEV-A)
See Antifungal Agents (FEV-B)
See Antiviral Agents (FEV-C)
Not for Distribution