A. Trimethoprim/sulfamethoxazole
Some evidence indicates that children have fewer serious bacterial infections; deaths related to infection; and episodes of otitis media, upper respiratory infection, urinary tract infection, cellulitis, pneumonitis, and sinusitis when prophylactic TMP/SMX is given. The following recommendations are made to ensure uniformity in multi-institutional trials.
1. Patients on chemotherapy should receive prophylactic TMP/SMX unless they have
a. Allergy to TMP or SMX
b. Glucose-6-phosphate dehydrogenase deficiency
c. Malabsorption
2. Schedule
a. Patients should commence TMP/SMX prophylaxis at the time of the diagnosis whether or not systemic antibiotic therapy is also indicated.
b. Patients on aggressive regimens for whom the ANC can
be expected to be < 500/uL for more than 14 days
should take TMP/SMX daily when starting the
chemotherapy in the hopes of diminishing the occurrence of bacterial infection.
c. Patients on nonaggressive regimens of chemotherapy or those receiving systemic antibiotic therapy should
be given TMP/SMX 3 consecutive days each week.
d. Patients should discontinue TMP/SMX 1 day before and for 4 days after infusion of high-dose methotrexate.
e. Bone marrow transplant recipients should discontinue TMP/SMX 2 days before transplantation and then
restart it when the ANC is > 500/uL.
Dosage (see Section IIB)
Preparations (see Section IIC)
B. Other antimicrobial agents
The quinolones ofloxacin, norfloxacin, and ciprofloxacin have shown promise in adult prophylactic studies. Ciprofloxacin appears to have the broadest antibacterial effect and should be considered as prophylaxis in the neutropenic young adult with cancer; however, ciprofloxacin is not approved by the Food and Drug Administration for use in children. The dosage usually used for ciprofloxacin is 500 mg b.i.d.
C. Prophylaxis against Haemophilus influenzae type b
The use of H. influenzae vaccine for children older than 2 months is recommended; however, remember that patients who receive very intense chemotherapeutic regimens may not form or maintain antibodies to H. influenzae,
Patients who have contact within the household or who have prolonged exposure to individuals with severe H. influenzae infection should receive rifampin prophylaxis regardless of their age.
Dosage: 20 mg/kg/day of rifampin: (maximum 600 mg) PO for 4 days
Preparations
a. Capsule: 150 or 300 mg. Powders can be preweighed by a pharmacist to give precise dosages.
b. Rifampin suspension (1% in simple syrup) can be prepared by a pharmacist.
D. Intravenous immune globulin
Determine the use of intravenous immune globulin for bacterial prophylaxis for each study. Specifically designate whether or not it is to be used.
Dosage: 200-400 mg/kg once a month
Preparations vary. Listed are several:
a. 5% solution (Cutter): 10, 50, or 100 mL vials
b. Lyophilized powder (Sandoz): 1, 3, or 6 g vials
Reconstitution fluid is provided to prepare a 3, 6, 9, or 12% solution.
4. Administer in a separate IV line starting at 0.5-1.0
mg/kg/min for 15 minutes, 3 mg/kg/min for 15 minutes, and then 4 mg/kg/min until completed.
Compatible with 0.9% saline
Give the IV preparation only intravenously; never use the intramuscular (IM) preparation intravenously.
Side effects
a. Interstitial extravasation can result in local irritation,
inflammation, and phlebitis secondary to the alkaline
pH.
b. Rapid intravenous infusion can result in reversible
increases in serum creatinine concentrations.
c. A small percentage of patients may experience nausea, vomiting, headache, diarrhea, and/or rash.
d. Anaphylactoid reaction in agammaglobulinemic or IgA-deficient patients
e. Inflammatory reactions: fever, fatigue, shivering, local pain
f. Hypersensitivity reactions
g. Headaches, aseptic meningitis syndrome
E. Splenectomized children
Splenectomized children are susceptible to overwhelming infections with encapsulated bacteria.
Penicillin, amoxicillin, or erythromycin may be used for antibiotic prophylaxis. Dosage recommendations are as follows:
a. Penicillin > 14 years: 250-500 mg b.i.d. 5-14 years: 250 mg b.i.d. 1-5 years: 125 mg b.i.d.
b. Amoxicillin > 14 years: 250-500 mg daily 5-14 years: 125 mg daily 1-5 years: 10 mg/kg/day
c. Erythromycin (base) > 8 years: 250-500 mg daily 2-8 years: 150 mg daily 1-2 years: 125 mg daily
3. Vaccination (see IIA-Z)
a. Polyvalent pneumococcal vaccine: 0.5 mL IM for children > 2 years old
b. Haemophilus type b conjugate vaccine: 0.5 mL IM for children > 2 months old
See the manufacturer's recommendations for the number of injections required.
c. Quadrivalent meningococcal polysaccharide vaccine
*3\168\2*
Cancer
