The American Society of Clinical Oncology (ASCO) has issued a new guideline on how and when to prevent infection in chemotherapy outpatients who are neutropenic but not febrile. It provides advice on identifying patients who have both neutropenia and fever but are at low risk for complications and can be treated at home. The new guidance, published online January 14 in the Journal of Clinical Oncology, is a logical progression.
“The new guideline recommends that physicians attempt to prevent infection in outpatients with “profound” neutropenia but no fever. It advises using antibacterial and antifungal prophylaxis if neutrophils are expected to remain below 100/uL for more than 7 days, and says that the preferable agent for antibacterial prophylaxis is an oral fluoroquinolone and for antifungal prophylaxis is an oral triazole. This is not appropriate if other factors increase risks for complications or mortality, the authors add. Not recommended are interventions such as footwear exchange, protected environments, respiratory or surgical masks, neutropenic diet, or nutritional supplements; evidence of clinical benefits from these interventions is lacking, they note.
The use of antibacterial and antifungal prophylaxis is very restricted, and is limited to outpatients with profound neutropenia, said Dr. Malin, who was asked by Medscape Medical News for comment and was not on the ASCO panel. In the guideline, profound neutropenia is defined as an absolute neutrophil count below 100/uL (equivalent to less than 0.1 × 109/L).
“While it sounds complex, generally speaking, only regimens used in either the transplant setting or for patients with acute leukemia cause that degree of neutropenia,” she wrote in an email to Medscape Medical News.
The antibacterial and antifungal prophylaxis recommended by ASCO is generally not indicated when colony-stimulating factor (G-CSF) prophylaxis has already effectively reduced the depth and duration of neutropenia, Dr. Flowers and his coauthors point out.