NCCN Guidelines Index NCCN Guidelines Version 1.2014 Table of Contents Prevention and Treatment of Cancer-Related Infections Discussion NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Prevention and Treatment of Cancer-Related Infections Version 2.2016 NCCN.org Continue Version 2.2016, 05/20/16 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Brian Hill on 10/1/2016 3:49:18 PM. For personal use only. Not approved for distribution. Copyright © 2016 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Index NCCN Guidelines Version 2.2016 Infections Table of Contents Prevention and Treatment of Cancer-Related Infections Discussion * Lindsey Robert Baden, MD Chair Ф Erik R. Dubberke, MD Ф Þ Ken Rolston, MD Ф Þ Dana-Farber/Brigham and Women’s Siteman Cancer Center at Barnes- The University of Texas Cancer Center | Massachusetts General Jewish Hospital and Washington MD Anderson Cancer Center Hospital Cancer Center University School of Medicine Gowri Satyanarayana, MD Ф * Sankar Swaminathan, MD Vice-Chair Ф Ashley Morris Engemann, PharmD, BCOP Σ ‡ Vanderbilt-Ingram Cancer Center Huntsman Cancer Institute Duke Cancer Institute at the University of Utah * Brahm Segal, MD Ф * Alison G. Freifeld, MD Ф Þ Roswell Park Cancer Institute Michael Angarone, DO Ф Þ Fred & Pamela Buffett Cancer Center Robert H. Lurie Comprehensive Cancer * Susan K. Seo, MD Ф Þ Center of Northwestern University John N. Greene, MD Ф Þ Memorial Sloan Kettering Cancer Center Moffitt Cancer Center * Gayle Blouin, PharmD, BCOP Σ * Shmuel Shoham, MD Ф Massachuetts General Hospital James I. Ito, MD Ф Þ The Sidney Kimmel Comprehensive Cancer Center City of Hope Comprehensive Cancer Center at Johns Hopkins Cancer Center Bernard C. Camins, MD Ф * Randy Taplitz, MD Ф * Daniel R. Kaul, MD Ф University of Alabama at Birmingham University of Michigan UC San Diego Moores Cancer Center Comprehensive Cancer Center Comprehensive Cancer Center Jeffrey Topal, MD Þ * Corey Casper, MD, MPH Ф * Mark E. Lustberg, MD, PhD Ф Yale Cancer Center/Smilow Cancer Hospital Fred Hutchinson Cancer Research Center/ The Ohio State University Comprehensive Seattle Cancer Care Alliance Cancer Center - James Cancer Hospital * John W. Wilson, MD Ф and Solove Reseach Institute Mayo Clinic Cancer Center * Brenda Cooper, MD † Case Comprehensive Cancer Center/ Jose G. Montoya, MD Ф University Hospitals Seidman Cancer Stanford Cancer Institute Center and Cleveland Clinic Taussig Cancer Institute Ф Infectious diseases ‡ Hematology/Hematology oncology Þ Internal medicine X Pulmonary medicine NCCN Staff † Medical oncology Karin G. Hoffmann, RN, CCM Continue Σ Pharmacology Courtney Smith, PhD * Discussion section writing committee NCCN Guidelines Panel Disclosures Version 2.2016, 05/20/16 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Brian Hill on 10/1/2016 3:49:18 PM. For personal use only. Not approved for distribution. Copyright © 2016 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Index NCCN Guidelines Version 2.2016 Infections 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 Antimicrobial Prophylaxis (INF-1) the best management for any cancer Antifungal Prophylaxis (INF-2) patient is in a clinical trial. Prevention of Herpes Simplex Virus (HSV) and Varicella Zoster Virus (VZV) Reactivation or Participation in clinical trials is 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/physician.html. Antipneumocystis Prophylaxis (INF-6) General Recommendations for Vaccination in Patients with Cancer (INF-7) NCCN Categories of Evidence and All recommendations Recommended Vaccination Schedule After Autologous Or Allogeneic HCT(INF-8) Consensus: are category 2A unless otherwise Initial Evaluation of Fever and Neutropenia (FEV-1) specified. Initial Risk Assessment for Febrile Neutropenic Patients (FEV-2) Outpatient Therapy for Low-Risk Patients (FEV-3) See NCCN Categories of Evidence Initial Empiric Therapy For Fever And Neutropenia (FEV-5) and Consensus. 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 Table (FEV-A) Antifungal Agents Table (FEV-B) Antiviral Agents Table (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. ©2016. Version 2.2016, 05/20/16 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Brian Hill on 10/1/2016 3:49:18 PM. For personal use only. Not approved for distribution. Copyright © 2016 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Index NCCN Guidelines Version 2.2016 Infections Table of Contents Prevention and Treatment of Cancer-Related Infections Discussion Updates in Version 2.2016 of the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections from Version 2.2016 include: MS-1 • The discussion section was updated to reflect the changes in the algorithm. Updates in Version 2.2016 of the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections from Version 2.2015 include: INF-1 INF-3 continued • Overall Infection Risk In Patients With Cancer (Intermediate and High) • Disease/Therapy Examples: Alemtuzumab therapy/Allogeneic �Under Antimicrobial Prophylaxis, statement added: "Consider PCP HCT/GVHD requiring steroid treatment prophylaxis" �Minimum Duration revised: • Footnote "g" revised: "See Antiviral Agents (FEV-C) for dosing, ◊ "Minimum of 2 mo after alemtuzumab and until CD4 ≥200 spectrum, and specific comments/cautions. The antivirals are not cells/mcL During active therapy including periods of equal in terms of efficacy, side effects, and resistance." neutropenia and at least 30 d after HSCT" (Also for INF-3, INF-4, and INF-5) ◊ "Acyclovir Prophylaxis should be considered for at least 1 INF-2 y after allogeneic HSCT Preemptive therapy for CMV (See • Antifungal Prophylaxis INF-4) Antiviral therapy for HBV (See INF-5)" � For ALL,"Micafungin" was added. • Footnote "o" added: "For CMV antiviral prophylaxis, see INF-4. � For MDS (neutropenic), AML (neutropenic), and Significant GVHD, For HBV, HCV and HIV antiviral prophylaxis see INF-5." "Micafungin (category 2B)" was added. INF-4 � For Allogeneic HCT (neutropenic), Itraconazole (category 2B) was • Surveillance Period (High risk for CMV) removed. �Allogeneic hematopoietic stem cell transplant recipients � Footnote "k" revised: "Consider antifungal prophylaxis in all patients statement revised: with GVHD receiving immunosuppressive therapy (IST)" ◊ "Typically for 1 to 6 months after transplant" � Footnote "m" revised: "Itraconazole, voriconazole, and posaconazole ◊ "GVHD requiring therapy" are more potent inhibitors of hepatic cytochrome P450 3A4 �Footnote "p" revised: "CMV surveillance consists of at least isoenzymes than fluconazole and may significantly decrease the weekly monitoring by PCR or antigen testing." clearance of several agents used to treat cancer (eg, vincristine)." �Footnote "t" revised: "Foscarnet or cidofovir should be used INF-3 for cases of ganciclovir-resistant CMV or when ganciclovir • Overall Infection Risk In Patients With Cancer (Intermediate) is not tolerated (eg, ganciclovir-induced neutropenia � Minimum Duration revised: myelosuppression)." ◊ "Consider during active therapy and possibly longer depending on degree of immunosuppression at least 30 d after HSCT" ◊ "Consider for at least 1 y 6–12 months after autologous HSCT HCT after allogencic HCT and at least 6–12 months" Note: All recommendations are category 2A unless