The use of antibiotics in cancer patients with neutropenia
The most important changes in the recommendations concern the use of antibiotics in cancer patients with neutropenia: it is usual to distinguish between high and low risk groups, for each of which there are appropriate criteria to assess the risk and the recommended treatment regimens depending on the category.
The high-risk group consists of patients (1) with an expected duration of neutropenia greater than 7 days, with concomitant pathology, including (2) hemodynamic disorders, (3) inflammation of the mucous membrane of the oral cavity or intestines with dysphagia / diarrhea, (4) abdominal pain or pararectal area, (5) nausea / vomiting, diarrhea (more than 6 episodes of loose stools per day), (6) changes in neurological status / mental, (7) catheter-associated infection, (8) new focus of pulmonary infiltration, hypoxemia or concomitant chronic obstructive pulmonary disease, (8) liver failure (hepatic aminotransferase levels are more than 5 times higher than normal) and (9) renal failure (the creatinine clearance is less than 30 ml / min)
Low risk patients are those who should resolve neutropenia within 7 days in the absence of the concomitant illnesses listed above and with normal rates of kidney and liver function.
Initially, a bacteriological examination of two blood samples should be performed from both the catheter and the peripheral vein (ideally), or the two samples from the peripheral vein if the catheter is not installed. Sampling two samples from a catheter is not a diagnostic standard. Cultural studies of other samples can be carried out if necessary. In addition, an assessment of lung and liver function is required.
Anti-Pseudomonas beta-lactams (cefepime, ceftazidime, meropenem, imipenem or piperacillin / tazobactam) should be administered intravenously as a monotherapy to high-risk patients. Aminoglycosides, fluoroquinolones and / or vancomycin can be added to the treatment regimen for complicated cases or for resistance to pathogens.
Patients in the low risk group may receive the same intravenous therapy as patients at high risk or oral ciprofloxacin + amoxicillin / clavulanate. For penicillin allergies, levofloxacin, moxifloxacin, ciprofloxacin + azithromycin or ciprofloxacin + clindamycin may be prescribed.
High-risk patients with continuous or recurrent fever after 4 to 7 days of treatment should receive empirical antifungal therapy. Amphotericin B is the drug of choice; caspofungin, liposomal amphotericin B, itraconazole and voriconazole can also be used.
The appointment of a colony stimulating factor is not a useful addition to empirical antibiotic therapy.