Chapter 41

Antimicrobial Prophylaxis Regimen for Allogeneic Hematopoietic Stem Cell Transplant Recipients

Sherif Mossad

	Pre-engraftment (< 3 weeks)	Early post-engraftment (3 weeks–3 months) and late post-engraftment (<3 months)
Bacterial	Levofloxacin 500 mg PO or IV (due to mucositis) daily, or ciprofloxacin 500 mg PO BID Consider IVIg if IgG < 400 mg/dL	Amoxicillin 250 mg PO BID or azithromycin 250 mg PO daily (if allergic to penicillin) for ≥ 6 months; as long as immunosuppressive therapy is being administered Consider IVIg if IgG < 400 mg/dL
Fungal	Nystatin PO 500 000 units QID, or clotrimazole troches 10 mg PO TID, or amphotericin B suspension 500 mg PO QID, for oral mucosal prophylaxis Fluconazole 400 mg PO daily, or itraconazole solution 200 mg PO BID, or voriconazole 200 mg PO BID, or posaconazole 200 mg PO TID, or micafungin 50 mg IV QD, or ‘low dose’ amphotericin Ba (0.2 mg/kg/day) for systemic prophylaxis	Itraconazoleb solution 200 mg PO BID, or voriconazole 200 mg PO BID, or posaconazolec 200 mg PO TID, or micafungin 50 mg IV daily, or amphotericin Ba 0.5 mg/kg IV every other day for ≥ 6 months, as long as immunosuppressive therapy is being administered Routine monitoring of azole drug levels is controversial, but should be considered in patients with breakthrough infections
Viral	Acyclovir 400 mg PO BID, or famciclovir 250 mg PO BID, or valacyclovir 500 mg PO BID, or 2 g PO QID (if used for CMV prophylaxis) Weekly surveillance CMV antigenemia or CMV PCR, and pre-emptive treatment with IV ganciclovir, or alternative agent	Continue acyclovir, famciclovir, or valacyclovir for 1 year, unless ganciclovir or valganciclovir are used for CMV pre-emptive treatment or universal prophylaxis For CMV seropositive donors or recipients: Weekly surveillance CMV antigenemia or CMV PCR for ≥ 6 months, as long as immunosuppressive therapy is being administered, and pre-emptive treatment with IV ganciclovir, oral valganciclovir, or alternative agent (foscarnet or cidofovir) for at least 2 weeks; until surveillance test turns negative or Universal prophylaxis with IV ganciclovir 5 mg/kg/day, or valganciclovir 900 mg PO daily for 3 months after transplant
Pneumocystis jiroveci	Early prophylaxis is controversial due to risk of delayed engraftment with TMP-SMX	TMP-SMX 160/800 mg PO daily, or pentamidine 300 mg inhaled monthly, or dapsone 100 mg PO daily, or atovaquone 1500 mg PO daily for ≥ 6 months, as long as immunosuppressive therapy is being administered

BID, twice daily; CMV, cytomegalovirus; D+/R–, donor positive/recipient negative; GI, gastrointestinal; IgG, immunoglobulin G; IVIg, intravenous immunoglobulin; PCR, polymerase chain reaction; PO, by mouth; QD, once a day; QID, four times daily; TID, three times daily; TMP-SMX, trimethoprim-sulfamethoxazole.

aLipid formulations of amphotericin B may be substituted for conventional amphotericin B in patients with renal insufficiency.

bItraconazole solution should be taken on an empty stomach, and is better absorbed than itraconazole tablets taken with acidic fluid such as orange juice or cola drink.

cPosaconazole should be taken with high-fat food or liquid nutritional supplement.