Clin Transl Oncol DOI 10.1007/s12094-015-1442-4 CLINICAL GUIDES IN ONCOLOGY Management of infection and febrile neutropenia in patients with solid cancer 1 2 3 1 4 5 6 7 J. A. Virizuela • J. Carratala` • J. M. Aguado • D. Vicente • M. Salavert • M. Ruiz • I. Ruiz • F. Marco • 3 8 2,9 10 11 12 M. Lizasoain • P. Jime´nez-Fonseca • C. Gudiol • J. Cassinello • A. Carmona-Bayonas • M. Aguilar • J. J. Cruz13 Received: 2 October 2015 / Accepted: 26 October 2015 Ó Federacio´n de Sociedades Espan˜olas de Oncologı´a (FESEO) 2015 Abstract An expert group from the Spanish Society of vaccines, measures to control infection through vascular Infectious Diseases and Clinical Microbiology (SEIMC, catheters, and preventing infection in light of certain sur- for its acronym in Spanish) and the Spanish Society of gical maneuvers. The following is a revision of the criteria Medical Oncology (SEOM, for its acronym in Spanish) for febrile neutropenia management and the use of colony- have reviewed the main aspects to be considered when stimulating factors and closes with several guidelines for evaluating patients with solid cancer and infectious com- treating the cancer patient with serious infection. The plications contained in this article. Recommendations have, document concludes with a series of measures to control therefore, been put forth regarding the prophylaxis of the hospital infection. most prevalent infections in these patients, the use of Keywords Cancer Á Febrile neutropenia Á Infection Á Prophylaxis Á Risk factors Jordi Carratala`, Jose´ Marı´a Aguado, Miguel Salavert, Francesc Marco, Manuel Lizasoain, Carlota Gudiol, Manuela Aguilar: Members of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC). Juan Antonio Virizuela, David Vicente, Maribel Ruiz, Paula Jime´nez Fonseca, Javier Cassinello, Alberto Carmona-Bayonas, Juan Jesu´s Cruz: Members of the Spanish Society of Medical Oncology (SEOM). 8 & J. A. Virizuela Servicio de Oncologı´aMe´dica, Hospital Universitario [email protected] Central de Asturias, Oviedo, Asturias, Spain 9 Institut Catala` d’Oncologia, Barcelona, Spain 1 Servicio de Oncologı´aMe´dica, Hospital Universitario Virgen 10 de Macarena, Avda. Doctor Fedriani, 3, 41071 Seville, Spain Servicio de Oncologı´aMe´dica, Hospital Universitario de Guadalajara, Guadalajara, Spain 2 Servicio de Enfermedades Infecciosas, Hospital Universitari 11 de Bellvitge-IDIBELL, Universitat de Barcelona, Barcelona, Servicio de Hematologı´a y Oncologı´aMe´dica, Hospital Spain General Universitario Morales Meseguer, Murcia, Spain 12 3 Unidad de Enfermedades Infecciosas, Hospital Universitario Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre, Madrid, Spain Virgen del Rocı´o, Seville, Spain 13 4 Unidad de Enfermedades Infecciosas, Hospital Universitari i Servicio de Oncologı´aMe´dica, Hospital Clı´nico Polite`cnic La Fe, Valencia, Spain Universitario de Salamanca, Salamanca, Spain 5 Servicio de Oncologı´aMe´dica, Hospital Universitari Vall d’Hebron, Barcelona, Spain 6 Unidad de Enfermedades Infecciosas, Hospital Universitari Vall d’Hebron, Barcelona, Spain 7 Laboratori de Microbiologia, Centre de Diagno`stic Biome`dic (CDB), ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clı´nic, Universitat de Barcelona, Barcelona, Spain 123 Clin Transl Oncol Introduction gynecological checkup is also advised, as is screening for the human papilloma virus (HPV). Over the course of the last two decades, substantial head- The initial microbiological assessment is aimed at way has been made in the treatment of the cancer patient. screening for the most common chronic or latent infections Undoubtedly, one of the most outstanding advances has that may recrudesce in the event of immunosuppression been the decrease in infection-related morbimortality due and will depend on the type of chemotherapy administered to the progress achieved in preventing and treating these and on the specific risk of immunosuppression in each infections, as well as in shortening the period of neu- person. In general, depending on the chemotherapy, dura- tropenia, thanks to the use of hematopoietic growth factors. tion, immunosuppressant probability, and on the type of Despite these advances, infectious complications con- patient and their perspectives for survival, it is advisable to tinue to be one of the main causes of death in oncological know the serology for: (1) hepatitis A, B, and C virus patients. These individuals are subject to greater risk of (HAV, HBV, and HCV); (2) varicella zoster virus (VZV), certain infections being reactivated and are more likely to and (3) human immunodeficiency virus (HIV). Likewise, suffer nosocomial pathogens as a consequence of surgeries, tuberculosis (TBC) must be ruled out in the event of any the use of venous or urinary catheters and other devices, as uncertainty in this regard, people in contact with TBC or at well as the procedures they undergo. The emergence of risk populations, such as institutionalized individuals. multiresistant microorganisms in recent years has compli- There are regional diseases that must be taken into con- cated the issue of antibiotherapy in this population even sideration in patients from certain geographical areas further. Moreover, the growing use of new monoclonal (Table 1). antibodies and biological therapies has incremented the possibility of certain serious infections in these patients. While there are numerous clinical guidelines addressing Prevention the hematologic patient, few focus specifically on people with solid tumors. Experts from the Spanish Society of Vaccination Infectious Diseases and Clinical Microbiology (SEIMC, for its acronym in Spanish) and the Spanish Society of Table 2 contains the agents (obligatorily inactivated) to be Medical Oncology Me´dica (SEOM, for its acronym in used in these cases [1]. Vaccines containing attenuated live Spanish) have, therefore, undertaken to elaborate this microorganisms such as the rotavirus, 3-in-1 viral vaccine document, in which the pertinent information currently (measles, mumps, rubella), and chicken pox are con- available has been reviewed and recommendations based traindicated during chemotherapy [2]. on the best evidence available have been put forth, in the Patients with active solid tumors and those undergoing hope that they will help oncologists and specialists in chemotherapy must be vaccinated yearly for the flu [2]. It infectious medicine in their daily clinical practice and urge is recommended that they be immunized against pneumo- them to manage these patients together, in pursuit of coccus in accordance with the guidelines for immunode- optimal care for cancer patients with infectious disease. pressed patients. Depending on the aforementioned characteristics (type of chemotherapy, duration, clinical status), a booster dose Initial evaluation should be given against tetanus and diphtheria. Those who have not been protected against pertussis should be given The initial evaluation of cancer patients undertakes to the diphtheria, tetanus, and acellular pertussis vaccine detect active or latent infections at risk for reactivation in (DTaP). Likewise, HPV, meningococus, and HAV inocu- individuals with solid cancer who are to undergo poten- lations must be administered whenever there is a specific tially immunosuppressant treatment. indication. Immunization against HBV must be contem- The clinical assessment should include: (1) history of plated in unprotected individuals, after assessing their infectious diseases that may have remained latent and serological and clinical status. reactivate in the event of immunosuppression; (2) full The previously indicated agents should be given prior to epidemiological history, including contacts with patients initiating chemotherapy. Inactivated vaccines should be with infectious disease, as well as with other immunode- administered at least 2 weeks before beginning treatment pressed individuals; (3) patient’s origin and any visits or (with the exception of the flu vaccine, which will be given trips to countries outside our geographical area with yearly, even during chemotherapy), whereas attenuated endemic diseases that could be revived, and (4) history of live vaccines must be administered at least 4 weeks prior to possible drug reactions to antimicrobials. In women, a commencing treatment [3]. 123 Clin Transl Oncol Table 1 Regional or imported diseases by geographical area of procedence Country of procedence Probable Screening technique microorganism Mexico, Panama, Venezuela, Guatemala, or Southern US Histoplasma Serology capsulatum Southern US, Mexico, Guatemala, Honduras, Nicaragua, Argentina, Paraguay, Venezuela, Coccidioides immitis Serology and Colombia Caribbean, Southern Japan, Central and South America, Sub-Saharan Africa HTLV-I-II Serology Mexico, Central America, or Southern Cone (Chile, Argentina, Bolivia, Brazil, Paraguay) Trypanosoma cruzi Two serological techniques Tropical and subtropical regions, including Southern US Strongyloides Agar technique stercoralis Feces culture Serology Endemic areas for malaria during the last 2–5 years: asymptomatic parasitemias should be Plasmodium sp PCR ruled out Thick blood film HTLV-I-II: human T cell lymphotropic virus types I and II; PCR: polymerase chain reaction Table 2 Recommended vaccines for adults with solid tumors Vaccine Recommendation Regimen Pneumococcus Recommended 1st dose (VNC13) at diagnosis prior to treatment; subsequent doses: one VNP23 dose at 8 weeks Influenza Recommended Yearly