Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of Americaa
Alison G. Freifeld,1 Eric J. Bow,9 Kent A. Sepkowitz,2 Michael J. Boeckh,4 James I. Ito,5 Craig A. Mullen,3 Issam I. Raad,6 Kenneth V. Rolston,6 Jo-Anne H. Young,7 and John R. Wingard8
1Department of Medicine,University of Nebraska Medical Center, Omaha, Nebraska; 2Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York; 3Department of Pediatrics, University of Rochester Medical Center, Rochester, New York; 4Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research, Seattle, Washington; 5Division of Infectious Diseases, City of Hope National Medical Center, Duarte, California;6Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas; 7Department of Medicine, University of Minnesota, Minneapolis, Minnesota; 8Division of Hematology/Oncology, University of Florida, Gainesville, Florida; and 9Departments of Medical Microbiology and Internal Medicine, the University of Manitoba, andInfection Control Services, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
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This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that was published in 1997 and ﬁrst updated in 2002. It is intended as a guide for the use of antimicrobial agents in managingpatients with cancer who experience chemotherapy-induced fever and neutropenia. Recent advances in antimicrobial drug development and technology, clinical trial results, and extensive clinical experience have informed the approaches and recommendations herein. Because the previous iteration of this guideline in 2002, we have a developed a clearer deﬁnition of which populations of patients with cancermay beneﬁt most from antibiotic, antifungal, and antiviral prophylaxis. Furthermore, categorizing neutropenic patients as being at high risk or low risk for infection according to presenting signs and symptoms, underlying cancer, type of therapy, and medical comorbidities has become essential to the treatment algorithm. Risk stratiﬁcation is a recommended starting point for managing patients withfever and neutropenia. In addition, earlier detection of invasive fungal infections has led to debate regarding optimal use of empirical or preemptive antifungal therapy, although algorithms are still evolving. What has not changed is the indication for immediate empirical antibiotic therapy. It remains true that all patients who present with fever and neutropenia should be treated swiftly andbroadly with antibiotics to treat both gram-positive and gram-negative pathogens. Finally, we note that all Panel members are from institutions in the United States or Canada; thus, these guidelines were developed in the context of North American practices. Some recommendations may not be as applicable outside of North America, in areas where differences in available antibiotics, in the predominantpathogens, and/or in health care–associated economic conditions exist. Regardless of venue, clinical vigilance and immediate treatment are the universal keys to managing neutropenic patients with fever and/or infection.
EXECUTIVE SUMMARY Fever during chemotherapy-induced neutropenia may be the only indication of a severe underlying infection, because signs and symptoms of inﬂammation typically areattenuated. Physicians must be keenly aware of the infection risks, diagnostic methods, and antimicrobial therapies required for management of febrile patients through the neutropenic period. Accordingly, algorithmic approaches to fever and neutropenia, infection prophylaxis, diagnosis, and treatment have been
Clinical Practice Guidelines
Received 29 October 2010; accepted 17 November...