Typical protocols include

• Isolation procedures —strict handwashing by all patient contacts is the only isolation measure of universally proven benefit. Others include visitor restriction, gloves, aprons, gowns, masks and full reverse barrier nursing. Isolation rooms with positive pressure filtered air will prevent fungal infection.

• Drinks —avoid mains tap water/still mineral water (use boiled water or sparkling mineral water). Avoid unpasteurised milk and freshly squeezed fruit juice.

• Food —avoid cream, ice-cream, soft, blue or ripened cheeses, live yoghurt, raw eggs or derived foods e.g. mayonnaise and soufflés, cold chicken, meat paté, raw fish/shellfish, unpeeled fresh vegetables/salads, unpeeled fruit, uncooked herbs and spices, ground pepper (contains Aspergillus spores).

• General mouthcare —antiseptic mouthwash e.g. Corsadyl 10mL 4 hourly swish and spit. If soreness develops, substitute Difflam mouthwash. For discrete oral ulcers, use topical Adcortyl in Orobase; for generalised ulceration use 0.9% saline mouthwash hourly, swish and spit. Corsodyl toothpaste should replace standard preparations. Oral antifungal prophylaxis should be nystatin susp. 1mL 4 hourly swish and spit or swallow, or amphotericin lozenges one to suck slowly 4 hourly.

• Antibacterial prophylaxis —aim to alter flora and prevent exogenous 550 colonisation. Principal agents: ciprofloxacin 250mg bd or cotrimoxa-

zole 480mg bd or colistin 1.5MU tds and neomycin 500mg qds. All given PO starting 48h after antifungal prophylaxis.

• Antifungal prophylaxis —a systemic imidazole compound is most routinely used e.g. fluconazole 100mg PO od. Itraconazole liquid 2.5mg/kg bd PO may offer additional protection against Aspergillus.

• Antiviral prophylaxis —Acyclovir is the most useful drug at preventing herpes reactivation. Dose is dependent on degree of immuno-suppression and thus the likely organism to be encountered. 400mg bd will prevent HSV reactivation e.g. post-standard chemotherapy; 400mg qds may prevent HZV reactivation e.g. post-SCT; 800mg tds or more may prevent CMV reactivation post-allogeneic SCT.

• Additional prophylaxis for specials situations —history of, or radiological evidence of, tuberculosis (TB). Consideration should be given to standard anti-TB prophylaxis e.g. rimactazid/pyridoxine particularly if prolonged neutropenia expected. Splenectomised patient—at extra risk from encapsulated organisms particularly Streptococcus pneumoniae, Haemophilusinfluenzae and Neisseria meningitidis. Use penicillin V 500mg od PO or erythromycin 250 mg od PO if penicillin allergic as prophylaxis switching to high dose amoxicillin/cefotaxime if febrile. Post-SCT (see p294).

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