NCCN Guidelines and Compendium Updated
Flash Update sent September 25, 2012
NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Prevention and Treatment of Cancer-Related Infections. These NCCN Guidelines® are currently available as Version 1.2012.
- Under antifungal prophylaxis (INF-2), added "Fluconazole (category 2B)" to the MDS/AML pathway.
- Under antiviral prophylaxis (INF-3), for intermediate, added "Consider VZV prophylaxis given for at least 1 year after HSCT." Also following bortezomib, changed the duration of antiviral prophylaxis to "During active therapy."
- Prevention of Cytomegalovirus (CMV) Reactivation or Disease (INF-4) included "Cidofovir (IV)" as a treatment option.
- Added a new footnote defining pre-emptive therapy (INF-4), "Defined as administration of antiviral agents to patients (who may be asymptomatic) at high risk for clinical infection based on laboratory markers of viremia (eg, increase in viral DNA load in serum or blood)."
- Included a new pathway for "Prevention of HBV Reactivation or Disease" (INF-5).
- High risk for Pneumocystis jirovecii (Pneumocystis carinii) (INF-6), for the alemtuzumab pathway, modified the duration to state "For a minimum of 2 mo after alemtuzumab and until CD4 count is greater the 200 cells/mcL."
- Following TMP/SMX (INF-6), added a new footnote, "In addition, this agent has some activity against other pathogens (eg, Nocardia, Toxoplasma, Listeria)."
- Outpatient therapy for low-risk patients (FEV-4), added a new footnote after "Daily long-acting intravenous agent ± oral therapy" to indicate that "Agents active against Pseudomonas should be included."
- Initial Empiric Therapy for Uncomplicated Fever and Neutropenia (FEV-5), added a new bullet: "IV combination therapy not routinely recommended except for complicated cases or resistance."
- Replaced "Cellulitis" with "Cellulitis/skin and soft tissue infection" (FEV-9).
- For the CNS pathway (FEV-9), added a new bullet: "Initiate empiric therapy pending infectious disease consult."
- Fever of unknown origin (FEV-10), added a new footnote: "In the case of prolonged neutropenia (>14 d), consider judicious assessment of empiric therapy."
- Antibacterial Agents: Gram-Positive Activity (FEV-A, 1 of 4)
- Added the oral dose for vancomycin (for C. difficile, 125 mg PO every 6 h).
- Changed the dose ranges for daptomycin (to 4-6 mg/kg/d IV).
- Added ceftaroline to the table.
- Antibacterial Agents: Antipseudomonal (FEV-A, 2 of 4)
- Added a footnote stating "Emerging data may support continuous infusion use for higher potency against resistant cases."
- Cefepime, added a bullet under spectrum stating, "Not active against most anaerobes and Enterococcus spp."
- Antibacterial Agents: Other (FEV-A, 3 of 4)
- For ciprofloxacin, added the dose for combination (for low risk, 500 mg PO every 8 h + amoxicillin/clavulanate 500 mg every 8h). Also added a footnote, "Consider adding a second agent in cases of severe infection based on local susceptibility pattern."
- Antifungal Agents: Azoles (FEV-B, 1 of 4)
- Posaconazole, modified the 3rd bullet under "Comments/Precaution" to "Should be administered with a full meal or liquid nutritional supplement or an acidic carbonated beverage." Also added a new bullet: "PPls (eg, esomeprazole) may decrease posaconazole plasma concentration."
- Antifungal Agents: Echinocandins (FEV-B, 3 of 4)
- Added a bullet to the dose for micafungin: "150 mg/d IV used at some centers for Aspergillus spp. infection."
- Antiviral Agents (FEV-C, 1 of 4)
- For ganciclovir, under "Treatment" modified recommendation to state, "Formulations and dosages of IVIG vary in different series." Also added HHV-6 under Spectrum.
- Antiviral Agents (FEV-C, 2 of 4)
- For foscarnet, added "HHV-6" under Spectrum.
- For cidofovir, added "adenovirus" under Spectrum.
- Antiviral Agents (FEV-C, 3 of 4)
- Removed information for "pegylated interferon alpha" and
- Added information for other agents active against HBV: adefovir, entecavir and telbivudine were added to the table.
- Appropriate Use Of Vancomycin And Other Agents For Gram-positive Resistant Infections (FEV-F)
- Modified the second bullet to state, "If an agent for Gram-positive resistant infection is initiated empirically, it should be discontinued in 2-3 days if a resistant Gram-positive organism (eg, MRSA) is not identified."
- Added the last bullet: "Oral vancomycin recommended in management of C. difficile infection."
- Discussion: The discussion sections for infectious risk evaluation and prevention of infections have been updated to reflect the changes in the algorithm.
For the complete updated version of these and all NCCN Guidelines, visit NCCN.org.