NCCN has published updates to the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections

NCCN has published updates to the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections. These NCCN Guidelines are currently available as Version 1.2017.

  • Antimicrobial Prophylaxis (INF-1)
    • Footnote “i” was revised: “For patients who are intolerant to fluoroquinolone, consider TMP/SMX or an oral third-generation cephalosporin (category 2B).”
  • Antifungal Prophylaxis (INF-2)
    • Footnote “n” for “Micafungin” was added: “All three agents in the class (micafungin, caspofungin, anidulafungin) are considered by many to be interchangeable.”
    • Duration
      • Statement for “Allogeneic HCT (neutropenic)” was revised: “Continue during neutropenia “
      • Footnote “p” for “Allogeneic HCT (neutropenic)” was added: “Some studies continue treatment up to day 75.”
    • Antiviral Prophylaxis (INF-3)
      • Minimum Duration
        • Footnote “r” for “HSV prophylaxis” was added: “HSV prophylaxis is indicated in seropositive children.”
        • Footnote “s” for “VZV prophylaxis” was added: “For pediatric patients, prophylaxis for VZV is not routinely given unless there is a history of recurrent zoster infections or after first zoster while on myelosuppressive therapy, even if they are seropositive or vaccinated children.”
      • Prevention of Cytomegalovirus (CMV) Reactivation or Disease (INF-4)
        • Footnote “w” for “Allogeneic HCT recipients” was added: “Higher risk transplant subgroups may exist and require different management strategies.”
      • Prevention of Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV) Reactivation or Disease (INF-5)
        • Footnote “ee” for “Antivirals” was added: “Although data were originally obtained with lamivudine, entecavir and tenofovir are preferred agents, especially when treating patients with active infections due to the low threshold of resistance with lamivudine.“
      • High Risk for Pneumocystis jiroveccii (Pneumocystis carinii) in Patients with Cancer (INF-6)
        • “Idelalisib+/- rituxan” was added.
        • For “Duration of Prophylaxis”, “At least through active treatment” was added to “Idelalisib+/-rituxan” and “Recipients of prolonged corticosteroids or receiving temozolomide + radiation therapy”
        • Footnote “ll” for “Antipneumocystis Prophylaxis” was revised: “The list of agents is alphabetical and does not reflect preference. Consider TMP/SMX desensitization or atovaquone, dapsone, or pentamidine (aerosolized or IV) when PCP prophylaxis is required in patients who are TMP/SMX intolerant. For patients receiving dapsone, assessing G6PD levels prior to initiating therapy is recommended.”
      • General Recommendations for Vaccination in Patients with Cancer (INF-7)
        • 1st bullet, “General Comment” statement was revised: “Live viral vaccines should NOT be administered during chemotherapy or periods of significant immunosuppression, such as treatment of GVHD.”
        • 6th bullet was added: “Travel vaccines: ID consult for travel vaccines is recommended.”
      • Initial Risk Assessment for Febrile Neutropenic Patients (FEV-2)
        • 4th bullet under “High risk (any factor listed below)” was added: “Allogeneic cell transplant“
        • Footnote “b” was revised: “Risk categorization refers to risk of serious complications, including mortality, in patients with neutropenic fever. Risk stratification is validated in adults; no generalizable, cross-validated risk stratified management exists for pediatric patients with febrile neutropenia. See Risk Assessment Resources (FEV-D).” (Also for FEV-3)”
      • Outpatient Therapy for Low-Risk Patients (FEV-4)
        • Footnote “f” for the treatment option “ciprofloxacin plus amoxicillin/clavulanate” was revised: “Use clindamycin in place of amoxicillin-clavulanate for penicillin-allergic patients” (Also for FEV-5)
      • Initial Empiric Therapy for Fever and Neutropenia (FEV-5)
        • Footnote “j” for cefepime was revised: “An initial meta-analysis of clinical trials reported an increase in mortality among patients receiving cefepime versus other beta-lactams (Yahav D, Paul M, Fraser A, et al. Lancet Infect Dis 2007;7:338-348) Subsequent meta-analyses, including one from the FDA, showed no difference in mortality (Kim PW, Wu YT, Cooper C, et al. Clin Infect Dis 2010;51:381-389; Freifeld AG, Sepkowitz K. Clin Infect Dis 2010;51:390-391). Based on these results, the FDA has determined that cefepime remains an appropriate therapy for its approved indications.”
      • Evaluation of Diarrhea (FEV-7)
        • Two bullets were combined and revised: “Depending on clinical circumstances, consider viral pathogen testing (eg, adenovirus, rotavirus, and norovirus), bacterial cultures, and/or parasite exam “
      • Evaluation of Lung Infiltrates (FEV-8)
        • A sub-bullet was revised: “Consider BAL, including galactomannan and special stains or molecular techniques for identification of additional viral, protozoal, fungal, and bacterial pathogens, particularly if no response to initial therapy or if diffuse infiltrates present”
        • A sub-bullet was added to the empiric regimen: “Doxycycline for atypical organisms“
      • Antibacterial Agents: Empiric Gram-Positive Activity (FEV-A) (1 of 4)
        • For “b” was added for “Vancomycin”, ”Daptomycin”, and “Linezolid”: “Dosing is for adult patients. Consult pediatric guidelines for recommended dosing in these patients.“
      • Antibacterial Agents: Other (FEV-A) (3 of 4)
        • Metronidazole dosing was revised: “500 mg infused or oral every 6–8 h”
        • Trimethoprim/sulfamethoxazole (TMP/SMX) therapy dose was clarified: “Therapy: 15 mg/kg daily in divided doses based on the trimethoprim component“
        • For “Comments/Cautions”, a bullet was added for “Ciprofloxican in combination with Amoxicillin/clavulanate,” “Levofloxacin,” and “Moxifloxacin”: “Data support fluoroquinolones for prophylaxis; however,  in other clinical scenarios the risk: benefit analysis should be evaluated. Fluoroquinolone side effects should be taken into consideration (see the FDA warnings)“
      • Antifungal Agents: Azoles (FEV-B) (1 of 5)
        • Isavuconazonium sulfate
          • A statement was revised: “ Active against invasive aspergillosis and mucormycosis in patients with cancer and in HCT recipients“
          • Reference “1” was added: “Maertens JA, et al. Isavuconazole versus voriconazole for primary treatment of invasive mold disease caused by aspergillus and other filamentous fungi (SECURE): a phase 3, randomized-controlled, non-inferiority trial. Lancet 2016;387: 760-9.“
          • Reference”2″ was added: “Marty FM, Ostrosky-Zeichner L, Cornely OA, et al. Isavuconazole treatment for mucormycosis: a single-arm open-label trial and case-control analysis. Lancet Infect Dis 2016;16(7):828-837.“
          • Reference”3″ was added: “Patterson TF, Thompson GR, 3rd, Denning DW, et al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016;63(4): e1-e60“
        • Antifungal Agents: Azoles (FEV-B) (2 of 5)
          • Posaconazole dosing was revised: “ Loading dose 300 mg PO tablet BID on day 1 and then maintenance dose 300 mg PO daily; Loading dose 300 mg IV every 12 h on day 1 and then maintenance dose 300 mg IV daily “
          • A bullet under “Comments/Cautions” was added to “Posaconazole” and “Voriconazole”: “Potential drug interactions are important to consider“
          • Voriconazole dosing was revised:
            • ” Loading dose 200 mg PO BID for patients >40 kg or 100 mg PO BID for patients <40 kg IV 6 mg/kg every 12 h x 2 doses, then maintenance dose 4 mg/kg IV every 12 h (for invasive aspergillosis);”
            • ” Loading dose 6 mg/kg IV every 12 h x 2 doses, then maintenance dose 3–4 mg/kg IV every 12 h 200 mg PO BID for patients >40 kg or 100 mg PO BID for patients <40 kg for non-neutropenic patients with candidemia”
          • Antiviral Agents (FEV-C)
            • A bullet under “Comments/Cautions” was added to “Ganciclovir”, ”Valganciclovir”, and ”Foscarnet”: “Clinical data are limited for HHV-6 and HHV-8” (FEV-C 1 of 4 and 2 of 4)
            • A footnote was added to “Common Indication”: “Dosing is for adult patients. Consult pediatric guidelines for recommended dosing in these patients.” (FEV-C 1 of 4, 2 of 4, and 3 of 4)
            • Two bullets for “Intravenous immuno-globulin (IVIG)” under “Common Indication” were added: “Parvovirus B19, 400–500 mg/kg IV daily for 5 days” and “Adjunctive therapy for CMV and RSV pneumonitis, 400 mg/kg IV every other day for 3–5 doses” (FEV-C 3 of 4)
          • Risk Assessment Resources (FEV-D)
            • A footnote was added to the “MASCC Risk-Index Score/Model”: “MASCC risk-index is for adults only. It does not apply to pediatric patients.“

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