From the Guidelines
For neutropenia prophylaxis, Bactrim (trimethoprim-sulfamethoxazole) is generally preferred over Levaquin (levofloxacin) due to its broader spectrum of activity and lower risk of promoting bacterial resistance and Clostridioides difficile infections, as supported by the most recent guidelines from the National Comprehensive Cancer Network (1). The standard Bactrim prophylaxis regimen is one double-strength tablet (160mg trimethoprim/800mg sulfamethoxazole) daily or three times weekly. This medication specifically targets Pneumocystis jirovecii pneumonia and other common bacterial pathogens in neutropenic patients. Some key points to consider when choosing between Bactrim and Levaquin for neutropenia prophylaxis include:
- The patient's risk level for infection, with high-risk patients potentially benefiting from fluoroquinolone prophylaxis during neutropenia (1)
- The presence of sulfa allergies or intolerance, which may necessitate the use of alternative agents like Levaquin (1)
- The potential risks associated with Levaquin, including promoting bacterial resistance and Clostridioides difficile infections, as well as FDA warnings regarding tendon rupture and peripheral neuropathy with prolonged use (1)
- The importance of continuing prophylaxis throughout the neutropenic period and sometimes for several weeks afterward, depending on the underlying condition and immunosuppression severity (1) It's also worth noting that other alternatives, such as atovaquone, dapsone, or pentamidine, may be considered for patients with severe sulfa allergies or other specific prophylaxis goals and patient factors (1). Overall, the choice between Bactrim and Levaquin for neutropenia prophylaxis should be based on a careful consideration of the individual patient's needs and risk factors, as well as the most recent and highest-quality evidence available (1).
From the Research
Comparison of Bactrim and Levaquin for Neutropenia Prophylaxis
- Bactrim (Trimethoprim/Sulfamethoxazole) is recommended for patients at risk for Pneumocystis jiroveci pneumonia, such as those with childhood acute lymphoblastic leukemia 2.
- Levaquin (Levofloxacin) is preferred for quinolone prophylaxis in patients with an expected duration of neutropenia of more than 7 days 2.
- Fluoroquinolones, such as Levaquin, are preferred for antibacterial prophylaxis, while trimethoprim-sulfamethoxazole is preferred for Pneumocystis pneumonia (PCP) prophylaxis 3.
- Trimethoprim-sulfamethoxazole can significantly reduce infections and is highly effective in preventing pneumonia due to Pneumocystis carinii, but it can cause sulfonamide-related reactions, myelosuppression, oral candidiasis, and development of bacterial resistance 4.
- Quinolones, such as Levaquin, can reduce the occurrence of fever and infections in patients with neutropenia, but do not provide adequate coverage against gram-positive bacteria, and inappropriate use can induce resistance among gram-negative organisms 4.
Guidelines for Prophylaxis
- Antibacterial prophylaxis is recommended for patients with neutropenia expected to exceed 7 days, with Levaquin being a preferred option 2.
- Trimethoprim-sulfamethoxazole is recommended for patients at risk for Pneumocystis jiroveci pneumonia 2.
- The choice of prophylaxis should take into account the individual patient's risk factors and local resistance patterns 3.
- Routine antibacterial prophylaxis is not recommended for patients likely to develop neutropenia, but may be considered for patients at high risk of severe infections 4.
Efficacy of Prophylaxis
- Intermittent dosing of trimethoprim-sulfamethoxazole on 2 consecutive days per week is an effective alternative prophylactic regimen for P. carinii pneumonia in pediatric patients with leukemia and lymphoma 5.
- A significant reduction in infections and bacteremia was seen in patients with malignancies other than acute non-lymphocytic leukemia who received oral trimethoprim-sulfamethoxazole 6.