INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

First line:

Febrile neutropenia

Fever 38ºC, neutrophil<500mm³

Enterobacteriaceae

(Klebsiella spp., Escherichia coli etc.), Pseudomonas spp., aerobic Gram positive (Staphylococci, Streptococci)

Cefepime 50mg/kg/dose IV in q8h

Piperacillin-tazobactam 300mg/kg/day IV in 3-4 divided doses (max. 16gm/day of piperacillin component)

Use monotherapy with an anti-pseudomonal β-lactam agents.

Second line:

Persistent fever > 72 hours*

Enterobacteriaceae (Klebsiella spp., Escherichia coli etc.), Pseudomonas, aerobic Gram  positive (Staphylococci, Streptococci), Enterococci or other resistant organisms

*DO NOT MODIFY INITIAL COVERAGE BASED SOLELY ON PERSISTENCE OF FEVER

Meropenem 60-120mg/ kg/day IV in 3 divided doses (max. 6gm/day)

PLUS*

Vancomycin 60mg/kg/ day in 3-4 divided doses (max. 2gm/day)

Escalate to second line if patient unstable to cover resistant Gram-negative, Gram-positive and anaerobes.

Consider adding Vancomycin in suspected catheter-related infections, positive blood culture for Gram-positive cocci, hypotensive patients and patients who are known to be colonised with MRSA. In patients responding to initial empiric antibiotic therapy, discontinue double coverage (empirical Vancomycin, if initiated) or double gram-negative after 24-72 hours if there is no specific microbiologic indication to continue combination therapy.

Third line:

Fever > 4-7 days with no identified source of fever

Candida spp., Aspergillus spp., Fusarium spp.

Viral: Respiratory viruses are the most common, HSV, VZV

Imipenem-cilastatin 60-100mg/kg/day IV in 4 divided doses (max. 4gm/day)

PLUS

Amphotericin B 0.5mg/ kg/dose IV q24h and gradually escalate by (0.25- 1mg/kg/dose q24h (max. 1.5mg/kg/day)

OR

Lipid formulation of amphotericin B 3-5mg/ kg/day

Imipenem-cilastatin 60-100mg/kg/day IV in 4 divided doses (max. 4gm/day)

PLUS

Caspofungin 70mg/m²/ dose IV q24h at Day 1, then 50mg/m²/dose IV q24h

1/3 of febrile neutropenic patients with persistent fever >1 week have systemic fungal infections.

In patients at high risk of invasive fungal disease with prolonged (≥96 hours) febrile neutropenia unresponsive to broad spectrum antibacterial agents, initiate antifungal.

Amphotericin based anti-fungal is considered more broad spectrum than echinocandin (e.g. Caspofungin)