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Af^un^Orug.

»nOCMnj»<i HfKCtryOft

• 'ftytuw» . «cnMnifor vancom^m

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• ANC than 100

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Stop *-S days an« ANC prMWtMn 500c«KnW

Stop *-S days an« ANC prMWtMn 500c«KnW

FIGURE 99-1. Management of febrile episodes in neutropenic cancer patients. (From Refs. 5, 12.) Table 99-8 Dosing Guidelines for Empiric Antimicrobial Agents in FN

fteg lint n Type_AgentsanJ Dosing

Comments

Antibacterial lactam monotherapy

Duaí 1he<ípy wi1h aiKtyHiudonwiidl P I.V. t.lTl plUS aminogl^oside impirk legimem {(Kiljininq vancomyïln containing fiixxw^iirtotone law risk aal regimen

An1ifwng.il

Liposomal àmpHO Off Kin A

CJsfX^uiiÇpn to"konajole

Cefepime [Vevsry E hours <Zef1a!kJime i tj IV every 6 hours Jriiijirnirfri wo t\? i^vfry iji li:!ir-Uenopenem I g Itf every 6 hours PlipeiidllnAJiobKim 4i D K ewy a hens

Cefepime, deirandniv?, imipenen\ meit^yvvfli, illin/iarotw urn (above dosagesi tlcancillinftlar.'ularnc aod £1 g IVevoryi hours ■ gcitamkln oi tobi almoin Ci'li'pime. ceit.n/idime» imipenem. mpitfienc«! dougK) + vancomycin ft£-) q every fc- li hours ±

Cipn)flc«icln 400 mq IVeve<yi hoo'S 4 pipeiacillin/la^obtKlafn, ceftazidime (jtXWdOMiWJ Ciprofloxacin 750 mg po every I? hours + WWwtiMii VcL^uUrWlt 9XJ-875 ro^i» every li hwri

JKf rng/Wj IV tudiïj dose on day 1 followed by sc: 'rli^'kii IV itn ">■

6 myAy IV kiadincj dose every I? hours on (fey 1 follow«) by * ni^Af) pdffl CvCy ii hcum

FtoeUyüí tit: 200 im^ po thiteiimei a day with food

Salvage: ÂKj mg po foui I ¡mes a day wilti food Tlwrt 4W pö Tw5 lirTi« ¿ CUy onre î<ahle

Although p()flfacillln/fa!QtHfiani tsnof recommended in the IKA guidelines, recent data demonstrate equivalence loothei nnmiiNi,i[v .intlilu.il llHi,if:y |.i|iTini', Alt (if itlM» ¿<J<yitIHqilte renal dose a<^uslment ard none require adjustment In hepatic dWunclio«i Wl cKfpi muropc.'nem rciiuutiidjuslniunl during

Gemaro < in or lobiamy: m ? mgikg loading dow followed by dtse^adjusird by ^emm forKpruralions: ontp daily (fcKirxr gi aminoglycosidesmay be ulilired. Both gomamicin and tobramycin rcguiii'icnjl doy.L adjustment bot are dosed bsscdniKiuifi tvili Neil hei gemamicln nor tobramycin requite hepalic dose Aciji.itment

Vancomwiin dosagei may be -adjusted hned on swum levels and -jie «Ijuiied it" lenjl ,ntl i:Ljly^r Nodowailj^imeiH i5

recommended foi hepatk dysfunction f inrvir be ir^vl in 1 vniffni lihn reieiw? fluoroquirK*jne prophylaiii■ Dose ad,its(ed in lerialdi^une and dialysis bu1 not foi hepaflic tfylfurKTian

For patlemswilh MASijC score greater than or equal toil not receiving fluOnXjuirWOnC propliylii'is. AntKriafrvtlanilWBie fc «JfuSHd ifi rc-r^l riiwjw and tlialy^hut run hepatic rtyskuvcion

I 'u'rmdkJloi with iXi-laminopfien and diphenhydramine^ iOJ mL rtonnji »line fcoiuHS beforf JAJ jiiei. Nodoit Jdi<]i(iineiti-iit lecofnmcoied for r^fiiloi hepstlc dyiftin((lon (y (¿luring fllalysli Lower lnc«Jence Of nephiolowtrly and ¡illusion rcaclcis; more HqMftfvi? Ho aOljiiVlnHnti we i^Yomnv^mt^tfi^ 11'11,11 It'piatk: dysfunction ch during dialysis. IX^aifi» adiustme<vi in In'fiiit. dysfunciio" biil not far IHHldbHK en tlialyiii ftjsatje adjustmenl in hepadic dysiunclion: IV Icxmulalion CtXfl'iinOkiWd If i>tilWiVtlMrJrxelC«irijn 50 KiLAnirX multlplpdru^ inteiaciom N0( I L1A Jiipiuved for prin ijry tx ijlvjgt ihf Juy riM1 irifasiw." rurfijal kriiHboH ihovgh iwd csncallyr (Hm^ of ch^ire per nCCn foi pophyla*isMi neutnopenk patienl* wilh AMI or N'lfH. Ho dose Kijuii merits Ruined ta itrvii or heiwii; dyifuixikjn <y duiirtg

AVI : Mil' myeloid IftikTITiiO: J!iy(H[xly^Jl,lMii -.yiKiloOií'. N(TN. N.Ukxi^l f olfl|ln'tifri>--tfeC.pihi 1 Mclwiiili f)0VrXf fty,il lui: paltBfïts; .íln isi dift« lor renal dyjíijnction

Empiric antifungal agents are typically added in persistently febrile patients after 5 to 7 days, especially if continued neutropenia is expected. Amphotericin B has historically been the drug of choice due to its broad-spectrum activity against both yeast (Candida spp) and mold (Aspergillus spp) infections. Because frequent toxicity (nephrotoxicity, infusion reactions) limits the use of amphotericin B, less toxic alternatives have been studied. Lipid formulations of amphotericin provide decreased toxicity and liposomal amphotericin B (AmBisome) has been shown to be equivalent to conventional amphotericin B as empiric therapy, but is significantly more expensive. The role of voriconazole is unclear at this time; however, caspofungin has been shown to be equivalent with less toxicity when compared to liposomal amphotericin

B in a randomized trial and is FDA-approved for this indication. Itraconazole has also been used in some institutions, however, its use is complicated by poor bioavailability of oral preparations and numerous drug interactions. Posaconazole is a newer azole that is preferred by the NCCN for prophylactic use in neutropenic patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) and for patients with graft versus host disease (GVHD) while receiving intensive immunosuppressive therapy. It is not FDA-approved as primary or salvage therapy for the treatment of invasive fungal infections but it is approved by the European Union for invasive asper-gillosis and other fungal infections that are refractory to standard antifungal agents.

As stated earlier, low-risk patients fulfilling the MASCC criteria (Table 99-6) may be treated empirically as an out-patient with a regimen combining amoxicillin/clavu-lanic acid and ciprofloxacin. Ciprofloxacin and clindamycin are reasonable alternatives for penicillin-allergic patients.

The CSF should not routinely be utilized for treatment of FN in conjunction with antimicrobial therapy.19 However, the use of CSFs in certain high-risk patients with hypotension, documented fungal infection, pneumonia, or sepsis is reasonable. A recent meta-analysis demonstrated that hospitalization and neutrophil recovery are shortened and infection-related mortality is marginally improved.3 As with prophylactic use of these agents, cost considerations limit their use to high-risk patients.

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