Neutropenia prophylaxis

Anti-Pneumocystis Prophylaxis Sulfamethoxazole-trimethoprim (SMZ-TMP, cotrimoxazole) One SS tablet by mouth once a day3 One DS tablet by mouth once a day3 One DS tablet by mouth every MA/V/F3 Hyperkalemia Myelosuppression Nephrotoxicity Neutropenia Photosensitivity Rash... 

Antibiotic prophylaxis is warranted in high-risk patients (e.g., prolonged indwelling catheterization, positive urine cultures, and neutropenia) undergoing transurethral, perineal, or suprapubic resection of the prostate, resection of bladder tumors, or cystoscopy. 

Prevention of candidiasis in bone marrow transplant 400 mg once daily. In patients who are anticipated to have severe granulocytopenia (less than 500 neutrophils/mm ), start fluconazole prophylaxis several days before the anticipated onset of neutropenia, and continue for 7 days after the neutrophil count rises above 1000 cells/mm. ... 

Monitoring Because rifabutin may be associated with neutropenia, and, more rarely, thrombocytopenia, consider obtaining hematologic studies periodically in patients receiving prophylaxis. 

Lo N, Cullen M. Antibiotic prophylaxis in chemotherapy-induced neutropenia time to reconsider. Hematol Oncol 2006 24 120-5. 

After a meticulous review of the biomedical literature, the panel concluded that routine use of colony-stimulating factors for primary prophylaxis of febrile neutropenia in previously untreated patients is not justified by existing data. There is evidence, however, that colony-stimulation factor administration can decrease the probability of febrile neutropenia in subsequent cycles of chemotherapy after a documented occurrence in an earlier cycle. However, dose reduction after a severe episode, rather than administration of colony-stimulating factors, should be considered as a primary therapeutic option. In the absence of clinical evidence or other compelling reasons to maintain chemotherapy dose intensity, physicians should consider chemotherapy dose reduction... 

Lortholary O, Dupont B Antifungal prophylaxis during neutropenia and immunodeficiency. Clin Microbiol Rev 1997 10 477-504. 

Of 39 patients who had bone marrow transplants and who were randomized to receive either co-trimoxazole or atovaquone as prophylaxis in an open-label trial, eight taking co-trimoxazole withdrew because of presumed drug reactions, although in five of these the reported neutropenia and thrombocytopenia could have been a consequence of transplantation itself or of other drugs (2). None of 16 patients treated with atovaquone withdrew. This rate of reported adverse effects with co-trimoxazole is higher than usually reported in clinical practice with prophylactic dosages. 

The safety and efficacy of oral cyclodextrin itraconazole (5 mg/kg/day) as antifungal prophylaxis has been assessed in an open trial in 103 neutropenic children (median age 5 years range 0-15 years) (53). Prophylaxis was started at least 7 days before the onset of neutropenia and continued until neutrophil recovery. Of the 103 patients, only 47 completed the course of prophylaxis 27 withdrew because of poor compliance, 19 because of adverse events, and 10 for other reasons. Serious adverse events (other than death) occurred in 21 patients, including convulsions (n = 7), suspected drug interactions (n = 6), abdominal pain (n — 4), and constipation n — 4). The most common adverse events considered definitely or possibly related to itraconazole were vomiting (n = 12), abnormal liver function (n — 5), and abdominal pain (n = 3). Tolerabihty of the study medication at end-point was rated as good (55%), moderate (11%), poor (17%), or unacceptable (17%). There were no unexpected problems of safety or tolerability. 

Owing to the potential morbidity and mortality of infections in neutropenic cancer patients, measures have been taken to prevent these complications through a number of environmental modifications and prophylactic antimicrobial regimens. The goal of antimicrobial prophylaxis in cancer patients is to decrease the number and severity of systemic infections during prolonged periods of neutropenia. Decisions regarding prophylactic antimicrobials must be made with the realization of associated issues, such as resistance concerns. 

Munoz L, Martino R, Subira M, et al. Intensified prophylaxis of febrile neutropenia with ofloxacin plus rifampin during severe short-duration neutropenia in patients with lymphoma. Leuk Lymphoma 1999 34 585-589. 

---