Following a systematic review of the medical literature, a strong recommendation was made by a multinational, multidisciplinary expert panel against the routine use of systemic antibacterial prophylaxis (SAP) in pediatric patients with cancer and children undergoing hematopoietic stem cell transplantation (HSCT) unless prolonged severe neutropenia is likely to develop. These clinical practice guidelines were published in Clinical Infectious Diseases.

Although children with cancer undergoing intensive chemotherapy and pediatric recipients of HSCT are at increased risk of bacteremia and other invasive bacterial infections, potential benefits of SAP, such as decreased bacterial infection-related morbidity and mortality, must be weighed against the potential risks of this approach, including the development of antibiotic resistance, an increased likelihood of infection with Clostridioides difficile and fungal pathogens, as well as antibiotic-related toxicities.

Other recommendations in these guidelines include:

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  • Based on high-quality evidence, a weak recommendation was made for use of SAP in children with acute myeloid leukemia (AML) and those with relapsed acute lymphoblastic leukemia (ALL) who are at risk of severe neutropenia lasting 7 days or longer.
  • Based on low/moderate-quality evidence, weak recommendations were made against routine SAP in children receiving induction chemotherapy for newly diagnosed ALL or those undergoing autologous or allogeneic HSCT.
  • Based on low-quality evidence, a weak recommendation was made for limiting the duration of SAP to the anticipated period of severe neutropenia.
  • Based on moderate-quality evidence, a strong recommendation was made for use of levofloxacin as the preferred antibiotic for prophylactic use in children with cancer and pediatric recipients of HSCT.

Regarding the latter recommendations, the guideline panel noted that “although the data supported administration of a fluoroquinolone if systematic antibacterial prophylaxis is planned, the panel was concerned about reported adverse effects associated with these agents and levofloxacin in particular.”

Moreover, they commented that “patients and families should be informed about potential short- and long-term fluoroquinolone-related adverse effects prior to administration and this information may lead to some families choosing against prophylaxis.”

In addition, related areas representing knowledge gaps identified by the guideline panel as requiring further study included the need to identify subgroups of children with ALL undergoing induction chemotherapy and other children with solid tumors undergoing intensive chemotherapy at increased risk of prolonged, severe neutropenia.

Future research should evaluate the long-term effectiveness and adverse effects of prophylaxis,” the guideline panel noted.

Disclosures: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Lehrnbecher T, Fisher BT, Phillips B, et al. Guideline for antibacterial prophylaxis administration in pediatric cancer and hematopoietic stem cell transplantation. Clin Infect Dis. 2020;71(1):226-236. doi: 10.1093/cid/ciz1082