Antimicrobial therapy in the bone marrow transplant setting
Antimicrobial therapy in the bone marrow transplant setting
Clinical Condition Common Pathogens Empirical Antimicrobial Agents Alternate Antimicrobial Agents Comments
Febrile Neutropenia (FN)/ sepsis Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter species, Staphylococcus aureus, Coagulase Negative Staphylococci, Enterococcus species, Candida species Piperacillin-tazobactam + amikacin First line: Piperacillin-tazobactam + amikacin
Second line: Meropenem± Teicoplanin/Vancomycin
Third line or patient in septic shock: Meropenem+ Colistin/Polymyxin B± Teicoplanin/Vancomycin + caspofungin± Fosfomycin/Tigecycline 		Continue broad-spectrum antibiotics until the patient is afebrile for at least 2 days and the neutrophil count is >500 cells/mm3 on at least one occasion. If blood cultures are negative at 3 days following initiation of antibiotic the Teicoplanin/Vancomycin may be discontinued.
Note: Fosfomycin should be considered only in patients where Colistin Resistant Klebsiella/E. coli/Enterobacter are suspected.
Community acquired pneumonia (CAP) Streptococcus pneumoniae, Haemophilus influenzae, atypical agents (Mycoplasma, Chlamydia, Legionella), respiratory viruses (influenza A, influenza B, RSV, parainfluenza, rhinovirus, Enterovirus, human Metapneumovirus, Adenovirus, Coronavirus) Piperacillin-tazobactam+ clarithromycin/ azithromycin Meropenem+ clarithromycin or azithromycin+ Teicoplanin/Vancomycin If viral infection is suspected consider sending respiratory sample (nose and throat swab in viral transport media/ BAL/ endotracheal secretion) for respiratory viral PCR and consider early empirical use of oseltamivir. Oseltamivir may be discontinued once influenza PCR is negative
Health Care Associated Pneumonia (HAP) E. coli, Klebsiella, Pseudomonas, Acinetobacter, Staphylococcus aureus (methicillin resistant and methicillin sensitive) Meropenem+ Polymyxin B+ Teicoplanin/Vancomycin   Consider use of colistin with meropenem and Teicoplanin/Vancomycin in case of severe infection requiring respiratory support (ventilation) and this may be discontinued once cultures are negative and patient is stable. Also consider use of aerosolized colistin as an adjunct to intravenous antibiotics in the treatment of multi-drug resistant pathogens
Blood stream infection E. coli, Klebsiella, Pseudomonas, Acinetobacter, Staphylococcus aureus (methicillin resistant and methicillin sensitive), Staphylococcus epidermidis, Enterococcus species, Candida (albicans and non-albicans species of Candida) Stable patient: meropenem + amikacin   Second line/Unstable patient: Meropenem± Colistin ± Teicoplanin/Vancomycin ±
caspofungin 		Duration of treatment depends on the source of blood stream infection
Intravenous catheter associated infection Staphylococcus aureus, Staph. epidermidis, Coliforms (Enterobacteriaceae) and non-fermentative Gram negative bacilli Meropenem+ Vancomycin Meropenem+ Teicoplanin/Vancomycin+colistin Consider the use colistin/Polymyxin B or anti-fungal agents based on specific clinical/laboratory diagnosis
Skin and soft tissue infection Staphylococcus aureus, Streptococcus species, coliforms and non-fermentative Gram Negative Bacilli (in compromised host), Candida, Zygomycetes, Aspergillus, Fusarium Piperacillin-Tazobactam + Teicoplanin/ Vancomycin Necrotizing fasciitis: Meropenem+ Teicoplanin/Vancomycin + Clindamycin Consider the use of anti-fungal agents based on specific clinical/laboratory diagnosis. For MRSA coverage consider use of Teicoplanin/Vancomycin.
Consider the use of clindamycin where anti-toxin activity is desired (e.g. necrotizing fasciitis).
Intra-abdominal infection Coliforms and non-fermentativeGram Negative Bacilli, Anaerobes, Enterococcus species, Candida Piperacillin-Tazobactam+ Amikacin ± metronidazole Meropenem+  Teicoplanin/Vancomycin ± metronidazole Consider the use of anti-fungal agents based on specific clinical/laboratory diagnosis
Note: Piperacillin-tazobactam/meropenem provides good anaerobic cover. Addition of metronidazole to be considered only if enhanced anaerobic coverage is considered essential.
Urinary Tract infection Coliforms and non-fermentative Gram Negative Bacilli, Enterococcus species, Coagulase negative Staphylococci, Candida Piperacillin-Tazobactam+ Amikacin Meropenem+ Teicoplanin/Vancomycin Consider the use of anti-fungal agents based on specific clinical/laboratory diagnosis
Antibiotic associated diarrhoea Clostridium difficile Oral metronidazole Oral vancomycin Oral vancomycin may be used as first line in severe infections
Invasive pulmonary aspergillosis Aspergillus flavus,
Aspergillus fumigatus,
Aspergillus nidulans,
Aspergillus niger,
Aspergillus terreus		 Voriconazole Amphotericin B (preferably liposomal, otherwise conventional) Duration of therapy: ~ 6 weeks. Treatment should be continued until lesions have resolved or clinically stable.
Consider doing voriconazole therapeutic drug level monitoring (TDM) wherever feasible.
Mucormycosis Apophysomyces,
Basidiobolus,
Conidiobolus,
Cunninghamella,
Mortierella, Mucor,
Lichtheimia (Absidia),
Rhizomucor, Rhizopus,
Saksenaea,
Syncephalestrum 		Liposomal Amphotericin B with Surgical debridement (wherever feasible) Caspofungin may be considered along with liposomal amphotericin B Surgical debridement as far as possible. Antifungal therapy for mucormycosis should be continued until: there is resolution of clinical signs and symptoms of infection, there is resolution or stabilization of residual radiographic signs, there is resolution of underlying immunosuppression. Adjunctive therapies may be tried in case of non response.
Herpes simplex Herpes Simplex Virus Type 1 and Type 2 (HSV1, HSV2) Acyclovir or Valacyclovir Foscarnet Dose and Duration of therapy depends on organ involvement.
Varicella or disseminated zoster or localized zoster Varicella Zoster Virus Acyclovir or Valacyclovir Foscarnet Intravenous therapy is recommended in all severe and complicated cases.
CMV reactivation or disease (colitis, pneumonitis, hepatitis, retinitis, encephalitis) Cytomegalovirus Ganciclovir or Valgancyclovir Foscarnet or Cidofovir Treat till resolution of clinical symptoms and signs or resolution of viremia (2 negative viral load reports). In case of treatment failure with Ganciclovir, foscarnet is the drug of choice.
Pneumocystis jirovecii pneumonia Pneumocystis jirovecii Co-trimoxazole (10-15 mg/kg of TMP component in divided doses Clindamycin+ Primaquine Duration of therapy: 21 days Corticosteroids to be considered as an adjunctive therapy along with antimicrobial therapy against PCP.