NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Prevention and Treatment of Cancer-Related Infections Version 1.2019 — October 25, 2018 NCCN.org Continue Version 1.2019, 10/25/18 © National Comprehensive Cancer Network, Inc. 2018, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. http://guide.medlive.cn/ Printed by Maria Chen on 11/1/2018 9:41:49 PM. For personal use only. Not approved for distribution. Copyright © 2018 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Index NCCN Guidelines Version 1.2019 Table of Contents Prevention and Treatment of Cancer-Related Infections Discussion *Lindsey Robert Baden, MD Chair Ф Ashley Morris Engemann, PharmD, BCOP Σ ‡ Kenneth Rolston, MD Ф Þ Dana-Farber/Brigham and Women’s Cancer Duke Cancer Institute The University of Texas Center | Massachusetts General Hospital MD Anderson Cancer Center Cancer Center Alison G. Freifeld, MD Ф Þ Fred & Pamela Buffett Cancer Center Gowri Satyanarayana, MD Ф *Sankar Swaminathan, MD Vice-Chair Ф Vanderbilt-Ingram Cancer Center Huntsman Cancer Institute John N. Greene, MD Ф Þ at the University of Utah Moffitt Cancer Center Lucas Schulz, PharmD Σ University of Wisconsin Nikolaos G. Almyroudis, MD Ф Kevin Gregg, MD Ф Carbone Cancer Center Roswell Park Cancer Institute University of Michigan Rogel Cancer Center Susan K. Seo, MD Ф Þ Michael Angarone, DO Ф Þ Memorial Sloan Kettering Cancer Center Robert H. Lurie Comprehensive Cancer Hana Hakim, MD, MS € Ф Center of Northwestern University St. Jude Children’s Research Hospital/ Shmuel Shoham, MD Ф The University of Tennessee The Sidney Kimmel Comprehensive Gayle Blouin, PharmD, BCOP Σ Health Science Center Cancer Center at Johns Hopkins Massachuetts General Hospital Cancer Center James I. Ito, MD Ф Þ Randy Taplitz, MD Ф City of Hope National Medical Center UC San Diego Moores Cancer Center Bernard C. Camins, MD Ф University of Alabama at Birmingham Mark E. Lustberg, MD, PhD Ф Jeffrey Topal, MD Þ Comprehensive Cancer Center The Ohio State University Comprehensive Yale Cancer Center/Smilow Cancer Hospital Cancer Center - James Cancer Hospital Brenda Cooper, MD † and Solove Reseach Institute John W. Wilson, MD Ф Case Comprehensive Cancer Center/ Mayo Clinic Cancer Center University Hospitals Seidman Cancer Center Jose G. Montoya, MD Ф NCCN and Cleveland Clinic Taussig Cancer Institute Stanford Cancer Institute Alyse Johnson-Chilla, MS Erik R. Dubberke, MD Ф Þ Steven Pergam, MD Ф Þ Griselda Zuccarino-Catania, PhD Siteman Cancer Center at Barnes- Fred Hutchinson Cancer Research Center/ Jewish Hospital and Washington Seattle Cancer Care Alliance University School of Medicine Ф Infectious diseases Þ Internal medicine σ Pharmacology † Medical oncology ‡ Hematology/Hematology oncology € Pediatric oncology NCCN Guidelines Panel Disclosures Continue * Discussion section writing committee Version 1.2019, 10/25/18 © National Comprehensive Cancer Network, Inc. 2018, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. http://guide.medlive.cn/ Printed by Maria Chen on 11/1/2018 9:41:49 PM. For personal use only. Not approved for distribution. Copyright © 2018 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Index NCCN Guidelines Version 1.2019 Table of Contents Prevention and Treatment of Cancer-Related Infections Discussion NCCN Guidelines Prevention and Treatment of Cancer-Related Infections Panel Members Summary of the Guidelines Updates Clinical Trials: NCCN believes that the best management for any patient • Antimicrobial Prophylaxis (INF-1) with cancer is in a clinical trial. • Antifungal Prophylaxis (INF-2) Participation in clinical trials is • Prevention of Herpes Simplex Virus (HSV) and Varicella Zoster Virus (VZV) Reactivation or Disease (INF-3) especially encouraged. • Prevention of Cytomegalovirus (CMV) Reactivation or Disease (INF-4) To find clinical trials online at NCCN • Prevention of Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV) Member Institutions, click here: Reactivation or Disease (INF-5) nccn.org/clinical_trials/clinicians.aspx. • Antipneumocystis Prophylaxis (INF-6) NCCN Categories of Evidence and • General Recommendations for Vaccination in Patients with Cancer (INF-7) Consensus: All recommendations • Recommended Vaccination Schedule After Autologous or Allogeneic HCT (INF-8) are category 2A unless otherwise indicated. • Initial Evaluation of Fever and Neutropenia (FEV-1) • Initial Risk Assessment for Febrile Neutropenic Patients (FEV-2) See NCCN Categories of Evidence • Outpatient Therapy for Low-Risk Patients (FEV-3) and Consensus. • Initial Empiric Therapy for Fever and Neutropenia (FEV-5) • Site-Specific Evaluation and Therapy: Mouth/Mucosal Membrane, Esophagus, and Sinus/Nasal (FEV-6) Abdominal Pain, Perirectal Pain, Diarrhea, and Urinary Tract Symptoms (FEV-7) Lung Infiltrates (FEV-8) • Cellulitis/Skin and Soft Tissue Infections, Vascular Access Devices, Vesicular Lesions, Disseminated Papules or Other Lesions, and Central Nervous System Symptoms (FEV-9) • Principles of Daily Follow-Up (FEV-10) • Follow-Up Therapy for Responding Disease (FEV-11) Antibacterial Agents Tables (FEV-A) Antifungal Agents Tables (FEV-B) Antiviral Agents Tables (FEV-C) Risk Assessment Resources (FEV-D) The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2018. Version 1.2019, 10/25/18 © National Comprehensive Cancer Network, Inc. 2018, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. http://guide.medlive.cn/ Printed by Maria Chen on 11/1/2018 9:41:49 PM. For personal use only. Not approved for distribution. Copyright © 2018 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Index NCCN Guidelines Version 1.2019 Table of Contents Prevention and Treatment of Cancer-Related Infections Discussion Updates in Version 1.2019 of the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections from Version 1.2018 include: INF-1 INF-8 • Footnote d was updated: Pneumocystis prophylaxis (See INF- • Recombinant zoster vaccine was added to the table with 6). For dosing, spectrum, and specific comments/cautions, see corresponding footnote qq. Antibacterial Agents (FEV-A), Antifungal Agents (FEV-B), Antiviral FEV-4 Agents (FEV-C) as indicated. • Footnote e was updated: "The fluoroquinolone chosen should be • The following footnote was removed: "Although data support based on reliable Gram-negative bacillary activity, local antibacterial levofloxacin prophylaxis for low- and intermediate-risk patients, susceptibilities, and the use of quinolone prophylaxis of fever and the panel discourages this practice in low-risk patients because neutropenia." of concerns about antimicrobial resistance; however, it can be • Footnote g was updated: "Not active Insufficient activity against considered in intermediate-risk patients." pseudomonas. Recommended for low-risk patients who may not INF-2 require pseudomonas coverage." • "See Antipneumocytostis Prophylaxis (INF-6)" was added to FEV-5 Antifungal Prophylaxis. • The following footnotes were removed: • Footnote j was updated: "Itraconazole, voriconazole, and Consider local antibiotic susceptibility patterns when choosing posaconazole are more potent inhibitors of hepatic cytochrome empiric therapy. At hospitals where infections by antibiotic- P450 3A4 isoenzymes than fluconazole and may significantly resistant bacteria (eg, MRSA, drug-resistant Gram-negative rods) decrease the clearance of several agents used to treat cancer are commonly observed, policies on initial empiric therapy of (eg, vincristine). In select circumstances when standard therapy neutropenic fever may need to be tailored accordingly. is contraindicated, such as drug interactions in patients with An initial meta-analysis of clinical trials reported an increase leukemia or the risk of QTc prolongation, some centers consider in mortality among patients receiving cefepime versus other using echinocandins, amphotericin B at prophlyactic doses, or beta-lactams (Yahav D, Paul M, Fraser A, et al. Lancet Infect isavuconazole, although studies have not directly tested these." Dis 2007;7:338-348). Subsequent meta-analyses, including one INF-4 from the FDA, showed no difference in mortality (Kim PW, Wu • Letermovir was added as an option for primary prophylaxis for YT, Cooper C, et al. Clin Infect Dis 2010;51:381-389; Freifeld CMV+ allogeneic HCT recipients during the surveillance period with AG, Sepkowitz K. Clin Infect Dis 2010;51:390-391).