What antibiotics (abx) to give to a patient with non-Hodgkin lymphoma (NHL) on chemotherapy and radiation therapy with a potential lung infection and allergies to Augmentin (amoxicillin-clavulanate) and Ceftriaxone (ceftriaxone)?

Antibiotic Selection for Neutropenic Fever in Non-Hodgkin Lymphoma with Lung Infection and Beta-Lactam Allergies

For a patient with non-Hodgkin lymphoma on chemotherapy and radiation with suspected lung infection and allergies to Augmentin and ceftriaxone, use a respiratory fluoroquinolone (levofloxacin 750 mg daily or moxifloxacin 400 mg daily) as monotherapy, with consideration for adding vancomycin or linezolid if MRSA is suspected or the patient is severely ill. 1, 2, 3

Primary Antibiotic Recommendation

Respiratory Fluoroquinolone Monotherapy

• Levofloxacin 750 mg IV/PO once daily is the preferred first-line agent for this clinical scenario 1, 2

  • Provides excellent coverage against Streptococcus pneumoniae (including multi-drug resistant strains), Haemophilus influenzae, Moraxella catarrhalis, and atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella species) 1, 2
  • Clinical success rates of 90-95% for community-acquired pneumonia in clinical trials 2
  • Can be administered IV initially and switched to oral when clinically stable 1

• Moxifloxacin 400 mg IV/PO once daily is an equally effective alternative 1, 3

  • Has the highest antipneumococcal activity among fluoroquinolones 1, 3
  • Covers multi-drug resistant S. pneumoniae (MDRSP) effectively 3
  • Provides robust coverage against both typical and atypical respiratory pathogens 3

Additional Coverage Considerations

For Neutropenic Fever (Absolute Neutrophil Count <500/mm³)

Add empiric anti-MRSA coverage if the patient is severely ill, has skin/soft tissue involvement, or has risk factors for MRSA: 1

• Vancomycin 15-20 mg/kg IV every 8-12 hours (monitor serum levels and adjust accordingly) 1
• Linezolid 600 mg IV/PO every 12 hours as an alternative if vancomycin cannot be used 1

For Pseudomonas Risk Factors

If the patient has risk factors for Pseudomonas aeruginosa (recent hospitalization, frequent antibiotic use in last 3 months, severe disease, oral steroid use >10 mg prednisolone daily), do NOT use fluoroquinolone monotherapy 1:

• Use an antipseudomonal beta-lactam alternative: Since the patient is allergic to ceftriaxone and Augmentin, consider:
  • Aztreonam 2 g IV every 8 hours (safe in beta-lactam allergic patients as it has minimal cross-reactivity) 1
  • PLUS ciprofloxacin 400 mg IV every 12 hours or 750 mg PO twice daily 1
  • Alternatively, if aztreonam is unavailable: meropenem 2 g IV every 8 hours PLUS an aminoglycoside (gentamicin or tobramycin), though this requires careful assessment of beta-lactam allergy severity 1

Supportive Prophylaxis and Management

Antimicrobial Prophylaxis During Chemotherapy

• Antibacterial prophylaxis: Levofloxacin 500 mg PO daily or ciprofloxacin 500 mg PO daily should be started with onset of neutropenia and continued until ANC >500/mm³ 1
• Antipneumocystis prophylaxis: Trimethoprim-sulfamethoxazole three times weekly (or alternative if allergic) for at least 3-6 months post-chemotherapy or until CD4 >200 cells/mm³ 1
• Antiviral prophylaxis: Acyclovir 400 mg PO twice daily or valacyclovir 500 mg PO twice daily 1
• Antifungal prophylaxis: Fluconazole 400 mg PO daily from day of chemotherapy until ANC >1000/mm³ 1

Growth Factor Support

• Filgrastim 5 mcg/kg subcutaneously daily starting the day after chemotherapy completion until ANC recovery to reduce infection risk and duration of neutropenia 1
• Strongly recommended in patients receiving myelosuppressive chemotherapy for lymphoma 1

Treatment Duration and Monitoring

• Duration: 7-14 days for pneumonia, with shorter courses (5-7 days) acceptable if clinical response is rapid 1
• Clinical stability criteria: Temperature ≤37.8°C, heart rate ≤100 bpm, respiratory rate ≤24/min, systolic BP ≥90 mmHg, oxygen saturation ≥90%, ability to maintain oral intake, normal mental status 1
• Switch to oral therapy when patient meets clinical stability criteria for 24-48 hours 1

Critical Pitfalls to Avoid

• Do not use fluoroquinolone monotherapy if Pseudomonas risk factors are present - dual coverage is mandatory 1
• Do not delay antibiotic administration - initiate immediately upon diagnosis of infection in neutropenic patients 1
• Do not use macrolides alone given the patient's beta-lactam allergies and need for broader coverage 1
• Obtain blood and sputum cultures before starting antibiotics when feasible, but do not delay treatment 1
• Monitor for fluoroquinolone-associated adverse effects including tendon rupture, QT prolongation, and CNS effects 1, 2