Version July 2025
| Regimen | Antibacterial | Antifungal | Pneumocystis | HSV/VZV | CMV |
| BTK inhibitors | No | No | No*[2] | No¶[2] | No |
| Venetoclax | No | No | No | No | No |
| Anti-CD20 monoclonal antibodies (eg, rituximab, ofatumumab, obinutuzumab) | No | No | No | No | No |
| Duvelisib | No | No | Yes | No | CMV monitoringΔ |
| Alkylating agents (eg, chlorambucil) | No | No | No | No | No |
| Bendamustine | No | No | No | No | No |
| Purine analog monotherapy (eg, fludarabine) | No | No | No* | Yes | No |
| Purine analog – anti-CD20 monoclonal antibody | No | No | No | Yes | No |
| Chlorambucil – anti-CD20 monoclonal antibody | No | No | No | Yes | No |
| Purine analog – cyclophosphamide | No◊ | No | Yes | Yes | No |
| Purine analog – cyclophosphamide – anti-CD20 monoclonal antibody | No◊ | No | Yes | Yes | No |
| Alemtuzumab | No◊ | No§ | Yes | Yes | Weekly PCR monitoring¥ |
BTK: Bruton tyrosine kinase; CLL: chronic lymphocytic leukemia; CMV: cytomegalovirus; HSV: herpes simplex virus; PCR: polymerase chain reaction; VZV: varicella-zoster virus.
* Pneumocystis pneumonia has been reported in patients receiving this agent. Prophylaxis may be considered for those patients at higher risk of infection, such as heavily pretreated patients or those with prior opportunistic infections.
¶ HSV and VZV have been reported in patients receiving BTK inhibitors. Prophylaxis may be considered for those patients at higher risk of infection, such as heavily pretreated patients or those with a history of HSV and VZV infection.
Δ The manufacturer of duvelisib suggests that clinicians consider the use of prophylactic antivirals to prevent CMV infection and reactivation[1]. For patients who develop CMV infection, duvelisib should be withheld until infection resolves. If duvelisib is resumed after CMV infection, monitoring with CMV PCR or CMV antigenemia should be done at least monthly. For patients receiving either idelalisib or duvelisib, we determine the appropriateness of CMV prophylaxis on a case-by-case basis, balancing the risk of CMV reactivation with the risk of toxicity from CMV prophylaxis. When prophylaxis is not given, we monitor patients with a history of CMV infection or positive CMV serology closely as outlined above.
◊ The National Comprehensive Cancer Network suggests that fluoroquinolone prophylaxis be considered during neutropenia for intermediate-risk CLL patients.
§ When glucocorticoids are used in combination with alemtuzumab, we give antifungal prophylaxis.
¥ We give preemptive therapy with valganciclovir to those with a positive CMV PCR result. Some experts prefer giving prophylaxis rather than preemptive therapy.