From the Guidelines
The recommended fluoroquinolone prophylaxis regimen for high-risk neutropenic patients with hematological disorders is levofloxacin 500 mg orally once daily or ciprofloxacin 500 mg orally twice daily, as stated in the guidelines by the Infectious Diseases Society of America 1. This prophylaxis should be initiated at the start of chemotherapy and continued until neutrophil recovery (typically when absolute neutrophil count exceeds 500 cells/mm³) or until resolution of neutropenia-associated fever requiring empiric antibiotics.
- Key considerations for fluoroquinolone prophylaxis include:
- Broad-spectrum activity against gram-negative bacteria, including Pseudomonas aeruginosa, which are common causes of life-threatening infections in neutropenic patients
- Some coverage against gram-positive organisms
- Monitoring for potential side effects including tendinitis, QT prolongation, and Clostridioides difficile infection
- Judicious use to minimize the development of antimicrobial resistance, considering local resistance patterns and institutional guidelines
- The decision to use fluoroquinolone prophylaxis should be based on the patient's risk of developing neutropenia, with levofloxacin and ciprofloxacin being roughly equivalent options, although levofloxacin is preferred in situations with increased risk for oral mucositis-related invasive viridans group streptococcal infection 1.
- It is essential to note that antibacterial prophylaxis is not routinely recommended for low-risk patients who are anticipated to remain neutropenic for less than 7 days 1.
From the Research
Quinolone Prophylaxis Regimens
- The recommended quinolone prophylaxis regimen for patients with hematological disorders at high risk of developing neutropenia is a topic of ongoing debate 2, 3, 4, 5, 6.
- Studies have shown that fluoroquinolone prophylaxis can reduce the incidence of febrile neutropenia and bacteremia in patients with hematological malignancies 4, 6.
- However, the use of quinolone prophylaxis has also been associated with the development of antibiotic resistance, including the emergence of quinolone-resistant Escherichia coli and extended-spectrum beta-lactamase (ESBL) producers 2, 3, 5, 6.
Specific Quinolone Prophylaxis Regimens
- Levofloxacin has been shown to be effective in preventing bacterial infection in patients with cancer and neutropenia, with a lower rate of microbiologically documented infections and bacteremias compared to placebo 4.
- Ciprofloxacin prophylaxis has also been shown to be beneficial in high-risk neutropenic patients, but has been associated with a higher rate of quinolone resistance and the use of carbapenems 2.
- The choice of quinolone prophylaxis regimen should be based on local antibiotic resistance patterns and the individual patient's risk factors 6.
Duration and Frequency of Quinolone Prophylaxis
- The optimal duration and frequency of quinolone prophylaxis are not well established, but studies suggest that repeated courses of prophylaxis can lead to the emergence of resistant bacteria 5.
- The recovery of the fecal microbiota to its initial composition after quinolone prophylaxis has not been fully evaluated, but studies suggest that the detection of quinolone-susceptible Enterobacteriaceae can recover before subsequent courses of prophylaxis 5.