Chapter 42

Antimicrobial Prophylaxis Regimen for Autologous 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 daily PO or IV (due to mucositis), or ciprofloxacin 500 mg BID Consider IVIg 400 mg/kg if IgG < 400 mg/dL	None
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 micafungin 50 mg IV daily, for systemic prophylaxis	Consider secondary prophylaxis for patients with previously confirmed invasive fungal infections
Viral	Acyclovir 400 mg PO BID, or famciclovir 250 mg PO BID, or valacyclovir 500 mg PO BID	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 patients who receive TBI, T-cell depleted grafts, or those who received alemtuzumab, fludarabine, or 2-CDA within 6 months prior to transplant, consider weekly surveillance CMV antigenemia or CMV PCR for ≥ 2 months, and pre-emptive treatment with IV ganciclovir, oral valganciclovir, or alternative agent (foscarnet or cidofovir) for at least 2 weeks, until surveillance test becomes negative
Pneumocystis jiroveci	Early prophylaxis is controversial due to risk of delayed engraftment with TMP-SMX	For patients with underlying leukemia, lymphoma, or myeloma who receive TBI, high-dose corticosteroids, T-cell-depleted grafts, or those who received alemtuzumab, fludarabine, or 2-CDA within 6 months prior to transplant, administer 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

BID, twice daily; CDA, chlorodeoxyadenosine; CMV, cytomegalovirus; IgG, immunoglobulin G; IVIg, intravenous immunoglobulin; PCR, polymerase chain reaction; PO, by mouth; QID, four times daily; TBI, total body irradiation; TID, three times daily; TMP-SMX, trimethoprim-sulfamethoxazole.

References: [1] Biol Blood Marrow Transplant 2009; 15(10): 1143; [2]LnID 2009; 9(2): 97; [3] National Comprehensive Cancer Network. Prevention and Treatment of Cancer-related Infections V.1.2008 (www.nccn.org); [4] Biol Blood Marrow Transplant 2006; 12(2): 138; [5] Ann Int Med 2003; 139: 8.