Infection Prophylaxis Update

TON - November/December 2014 Vol 7 No 6

With Ebola virus in the news, infection is a hot topic. At the recent National Comprehensive Cancer Network (NCCN) 9th Annual Congress: Hematologic Malignancies, Laura Zitella, MS, RN, ACNP-BC, AOCN, updated attendees on how to prevent and treat cancer-related infections.1 Zitella is with the Stanford Cancer Institute in Stanford, California.

“We can increase overall survival by risk-stratified prophylaxis. Assessment of risk is key. Prevention of infections is controversial and warrants additional research. Consider antimicrobial and antifungal prophylaxis for high-risk patients. Antiviral prophylaxis is recommended for patients at high risk of reactivation,” she stated.

“Hand washing is still the most effective strategy to prevent infection,” she reminded listeners.

There are also myths and old wives’ tales related to infection control. Restricting fruits and vegetables has not been proven to decrease infection, she continued.

Risk factors for infection include severity and duration of neutropenia because of disease and chemotherapy, status of malignancy, and breakdown of normal skin and mucosal barriers due to indwelling catheters or mucositis, and tumor-related obstruction.

Infection can also develop due to defects in humoral and cellular immunity resulting from cancer or its treatments. Such reactions may include altered B- and T-cell function in patients with lymphoid malignancies; those caused by treatment with steroids, anti-CD20 monoclonal antibodies, and purine analogs; or such defects caused by hypogammaglobulinemia or splenectomy.

Strategies for Prophylaxis
Potential strategies for prevention of infection include pharmacologic prophylaxis with antimicrobials, colony-stimulating growth factors, and vaccination. Nonpharmacologic approaches include neutropenic precautions and environmental interventions.

NCCN guidelines for prevention and treatment of cancer-related infections (version 2.2014) list key factors for low, intermediate, and high risk of infection.2 Prior to 2005, no survival benefit was found for antibiotic prophylaxis, but that changed in 2005 when a large meta-analysis of 95 randomized controlled trials found that antibiotic prophylaxis in afebrile neutropenic cancer patients reduced overall mortality by 33% and infection-related mortality by 42% versus placebo or no treatment.3 In the same study, fluoroquinolone prophylaxis reduced overall mortality by 48% and infection-related mortality by 62% versus placebo or no treatment.

More recently, a 2012 Cochrane review by the same author examining 109 trials that included 13,579 patients also showed a reduction in mortality for antibiotic prophylaxis, as well as a preference for quinolones over trimethoprim/sulfamethoxazole (TMP/SMX).4

“At present, consider antibiotic prophylaxis for all high-risk neutropenic patients, but not for low-risk patients. The drugs of choice are levofloxacin or ciprofloxacin,” Zitella said. “Continue to monitor patients on antibiotics for resistance.”

Colony-stimulating factors are recommended for patients with a 20% or greater risk of febrile neutropenia.5 “The caveat is that they are not routinely recommended for patients undergoing radiation therapy or treated for acute myeloid leukemia or Hodgkin’s disease patients,” Zitella stated.

Antifungal Prophylaxis
Antifungal prophylaxis is indicated for herpes simplex virus (HSV)-positive patients, such as those undergoing transplant, those with acute leukemia, or those undergoing treatment with proteasome inhibitors, alemtuzumab, or purine analogs; those with graft-versus-host disease being treated with steroids; or patients with prior HSV reactivation during treatment. Drugs of choice include valacyclovir, acyclovir, and famciclovir.

Cytomegalovirus (CMV) prophylaxis should be considered for high-risk patients who are CMV positive, such as those undergoing allogeneic transplant or treatment with alemtuzumab. If CMV viremia is detected, treatment should include valganciclovir, ganciclovir, foscarnet, or cidofovir.

“Hepatitis B virus [HBV] reactivation is emerging as an important pathogen in patients with hematologic malignancies,” Zitella continued. “HBV reactivation can lead to fulminant hepatitis and death,” she cautioned.

Patients undergoing stem cell transplant or immunosuppressive therapy may lose immune control of HBV. Testing for HBV is recommended for all patients undergoing immunosuppressive therapy, allogeneic stem cell transplant, treatment with anti-CD20 monoclonal antibodies and alemtuz­umab, and any patient with obvious risk factors for HBV. For patients who are hepatitis B surface antigen positive, antiviral prophylaxis is recommended with entecavir, tenofovir, adef­ovir, or telbivudine.

Patients with T-cell deficiency should be considered for Pneumocystis carinii pneumonia (PCP) prophylaxis, for which the drug of choice is TMP/SMX. Alternatives are atovaquone, dapsone, and inhaled pentamidine.

Regarding vaccines, Zitella said the recommendations have changed recently. “Do not give live attenuated vaccines to cancer patients.” Specific vaccine recommendations are available at the Centers for Disease Control and Prevention website and the NCCN website.




References
  1. Zitella L. Updates on the prevention and treatment of cancer-related infections. Presented at: National Comprehensive Cancer Network 9th Annual Congress: Hematologic Malignancies; September 19-20, 2014; New York, NY.
  2. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Prevention and Treatment of Cancer-Related Infections. Version 2.2014. http://www.nccn.org/professionals/physician_gls/pdf/infections.pdf. Accessed October 4, 2014.
  3. Gafter-Gvili A, Fraser A, Paul M, et al. Meta-analysis: antibiotic prophylaxis reduces mortality in neutropenic patients. Ann Intern Med. 2005;142(12 pt 1):979-995.
  4. Gafter-Gvili A, Fraser A, Paul M, et al. Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy. Cochrane Database Syst Rev. 2012;1:CD004386.
  5. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Myeloid Growth Factors. Version 2.2014. http://www.nccn.org/professionals/physician_gls/pdf/myeloid_growth.pdf. Accessed October 4, 2014.

Related Items


Subscribe Today!

To sign up for our newsletter or print publications, please enter your contact information below.

I'd like to receive: