Recommended antimicrobial prophylaxis by CLL treatment regimen

CLL: chronic lymphocytic leukemia; HSV: herpes simplex virus; VZV: varicella-zoster virus; CMV: cytomegalovirus; PCR: polymerase chain reaction.

* 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.

Δ We give preemptive therapy with valganciclovir to those with a positive CMV PCR result. Some experts prefer giving prophylaxis rather than preemptive therapy.

◊ In patients with a history of CMV infection or positive CMV serology receiving idelalisib, the manufacturer of idelalisib recommends that regular clinical and laboratory monitoring for CMV infection be performed^[1]. For patients who develop CMV infection while receiving idelalisib and in whom idelalisib is reinstituted, monitoring with CMV PCR or CMV antigenemia should be done at least monthly. The manufacturer of duvelisib suggests that clinicians consider the use of prophylactic antivirals to prevent CMV infection and reactivation^[2]. 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.