Antimicrobial prophylaxis regimens for adult patients with chronic lymphocytic leukemia (CLL)*

Antibacterial

Ciprofloxacin 500 or 750 mg orally twice daily

Levofloxacin 500 or 750 mg orally once daily

Antifungal

Fluconazole^¶ 200 or 400 mg orally once daily

Posaconazole^¶ delayed-release tablets 300 mg (three 100 mg tablets) orally every 12 hours on the first day, followed by 300 mg (three 100 mg tablets) once daily starting on the second day

Voriconazole^¶ 200 mg orally twice daily

Antiviral

HSV and VZV

Acyclovir

For HSV: 400 or 800 mg orally twice daily
For VZV: 800 mg orally twice daily

Valacyclovir 500 mg orally twice daily

Famciclovir 250 mg orally twice daily

CMV^Δ

Valganciclovir 900 mg orally once daily with food

Ganciclovir 5 mg/kg IV once daily

Pneumocystis

Preferred regimen:

Trimethoprim-sulfamethoxazole one single-strength tablet orally once daily or one double-strength tablet orally once daily or three times weekly^◊

Alternative regimens:

Dapsone 100 mg orally once daily or 50 mg orally twice daily

Pentamidine 300 mg by aerosol every four weeks

Atovaquone 1500 mg orally once daily with a high-fat meal

The doses above are intended for patients with normal renal function. The doses of many of the agents listed above must be adjusted in the setting of renal insufficiency. Many of the agents listed above can be given IV if the patient is unable to take oral medications. Refer to the Lexicomp drug specific monograph for renal dose adjustments and IV dosing.

HSV: herpes simplex virus; VZV: varicella-zoster virus; CMV: cytomegalovirus; IV: intravenously.
* Refer to the associated topic review for indications for antimicrobial prophylaxis.
¶ Posaconazole and voriconazole are potent inhibitors of CYP3A4 drug metabolism; fluconazole is a moderate inhibitor. Adjustment of antineoplastic therapy may be required. Readers may use Lexi-Interact, the drug interactions program included with UpToDate to determine specific interactions.
Δ Regular cytomegalovirus (CMV) surveillance testing followed by preemptive anti-CMV therapy for a positive result may be preferred over prophylaxis and is discussed in the topic review on prevention of infections in patients with CLL, section on alemtuzumab. Note that the dosing and schedule for preemptive anti-CMV therapy differs from the prophylaxis dosing shown in this table.
◊ Trimethoprim-sulfamethoxazole is preferred as it is the most effective regimen for Pneumocystis prophylaxis. It also provides activity against Toxoplasma gondii as well as certain bacteria (Nocardia spp, Listeria spp, some pneumococci).

Graphic 95619 Version 4.0

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Antimicrobial prophylaxis regimens for adult patients with chronic lymphocytic leukemia (CLL)*