Antimicrobial management and infection monitoring in patients with CRS and/or ICANS
| Management and monitoring . |
|---|
| • Empiric broad-spectrum antibiotics according to fever and neutropenia guidelines* |
| • ID consultation should be obtained to guide escalation and de-escalation of antimicrobial therapy, particularly in high-risk patients† |
| High-risk patients are those who meet any of the below criteria |
| o Receiving >1 dose of tocilizumab |
| o Requiring >3 days of ≥10 mg dexamethasone per day within a 7-day period |
| o Receiving 1 or more doses of methylprednisolone ≥1 g per day |
| o Receiving second-line agents for management of CRS or ICANS (eg, anakinra, siltuximab) |
| • Antibiotic de-escalation should be addressed on a daily basis with consideration for the type of immunosuppressive therapies that have been administered. |
| • Consider weekly CMV monitoring with serum polymerase chain reaction testing in high-risk patients who are CMV seropositive‡ |
| • Consider using mold-active azole prophylaxis with posaconazole in high-risk patients§ |
| Management and monitoring . |
|---|
| • Empiric broad-spectrum antibiotics according to fever and neutropenia guidelines* |
| • ID consultation should be obtained to guide escalation and de-escalation of antimicrobial therapy, particularly in high-risk patients† |
| High-risk patients are those who meet any of the below criteria |
| o Receiving >1 dose of tocilizumab |
| o Requiring >3 days of ≥10 mg dexamethasone per day within a 7-day period |
| o Receiving 1 or more doses of methylprednisolone ≥1 g per day |
| o Receiving second-line agents for management of CRS or ICANS (eg, anakinra, siltuximab) |
| • Antibiotic de-escalation should be addressed on a daily basis with consideration for the type of immunosuppressive therapies that have been administered. |
| • Consider weekly CMV monitoring with serum polymerase chain reaction testing in high-risk patients who are CMV seropositive‡ |
| • Consider using mold-active azole prophylaxis with posaconazole in high-risk patients§ |
For institutions that use cefepime as a first-ine antibiotic, alternatives with a similar spectrum (eg, piperacillin-tazobactam or ceftazidime plus vancomycin) can be considered in select cases in discussion with the ID consult service given that cefepime is independently associated with neurotoxicity in the context of older age and acute kidney injury.75
Because patients will differ in regard to their exposure history, antimicrobial prophylaxis, treatment of prior/concomitant infections, and other factors, the ID service should be consulted to help guide management of these highly complex patients who will benefit from interdisciplinary care.
Consider for 1 mo following the last dose of immunosuppressive therapies, but duration may be modified according to a patient’s clinical course. Consider preemptive therapy at CMV viral load thresholds according to institutional guidelines for autologous HCT recipients. The cost-effectiveness and clinical utility of this approach are unknown at this time and should be refined when more data are available.
Consider for 1 mo following the last dose of immunosuppressive therapies, but duration may be modified according to a patient’s clinical course. Voriconazole should be avoided when feasible because of the potential for neurotoxicity.76