The Infectious Diseases Society of America (IDSA) has recently updated the clinical practice guidelines for the use of antimicrobial agents in neutropenic patients. Expanding on earlier guidelines, the latest publication provides a clear protocol for physicians treating cancer patients who develop fever and neutropenia. The need for rapid empiric antibiotic therapy in these patients is highlighted, as is the importance of stratifying patients into high or low risk based on specific features. An overview of the updated guidelines is given here by Professor Thomas File, Jr. He also outlines the importance of these international guidelines for Asian physicians and provides a comprehensive summary on the role of individual antimicrobials.

Q01 What are the most important factors relating to antibiotic management of febrile neutropenia?

Criteria for the selection of antibiotics
Q02 Could you define febrile neutropenia?
Q03 In the US, patients with fever (≥38.3°C or 38.0°C) and absolute neutrophil count (ANC) (<500 cells/mm3) are treated with antibiotics while Japanese health insurance covers antibiotic therapy for patients with fever (>37.8°C) and ANC (<1,000 cells/mm3). Could you comment on the degree of fever required?
Q04 What role do antibiotics play in preventing neutropenic complications?
Q05 What important factors should be considered when choosing antibiotics for neutropenia?
Q06 What organisms cause infections in febrile neutropenic patients?
Q07 How do fluoroquinolones provide prophylaxis for neutropenic patients?
Q08 How do you decide duration of therapy when you give fluoroquinolones prophylactically?
Q09 Worries about resistance are stopping physicians using antibiotic prophylaxis. Is this preventing effective management in some cases?
Q10 Could you compare the use of fluoroquinolones in this setting with anti-pseudomonal beta-lactams or trimethoprim-sulfamethoxazole?
Q11 What challenges remain to be addressed and what further information will be useful to clinicians?
Q12 There are three therapeutic categories: prophylaxis, treatment of a presumed infection and treatment of an active infection. What factors need to be taken into account in such cases?

Vital points of the 2010 updated Infectious Diseases Society of America (IDSA) guidelines
Q13 Could you describe the background to the development of the 2010 IDSA guidelines for neutropenic patients?
Q14 Which patient populations do you regard as most likely to benefit from the IDSA guidelines?
Q15 What do the IDSA guidelines recommend for the empiric treatment of febrile neutropenia?
Q16 According to the IDSA guidelines, what is the role of fluoroquinolones? Could you also compare the use of levofloxacin with that of ciprofloxacin?
Q17 How can physicians choose the most appropriate antibiotic for use in their area?
Q18 Is there any specific reason why only ciprofloxacin is included in the algorithm of the IDSA guidelines?

Recommendations to Asian physicians who treat neutropenic patients
Q19 Could you make some specific recommendations to Asian physicians treating neutropenic patients? For example, what is the role of the infectious disease specialists in managing patients with febrile neutropenia?
Q20 What do the IDSA guidelines recommend regarding the use of granulocyte colony-stimulating factor (G-CSF) for neutropenic patients?
Q21 The IDSA guidelines were developed based on North American data. Do they need to be modified for Asian countries?
Q22 What additional evidence, such as microbacterial or clinical studies, is needed to develop specific Asian guidelines?
Q23 Access to antimicrobials differs around the world, and in many parts of Asia you can obtain over-the-counter (OTC) preparations. How would this affect the development of optimal Asian guidelines?
Q24 Could you provide a brief summary for physicians who wish to use levofloxacin or other fluoroquinolones as prophylaxis?
Q25 Some Asian physicians believe that they should use slightly lower doses because patients in Asia tend to be smaller. Do you have any data or would you still recommend the 500 mg dose of levofloxacin for preventive treatment and the 750 mg for active treatment in Asian patients?

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