# Antibacterial (fluoroquinolone) prophylaxis during expected severe neutropenia

Source: https://onco.cc/protocols/antibacterial-prophylaxis-in-neutropenia/  
OnCo record `antibacterial-prophylaxis-in-neutropenia` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Some people on intensive chemotherapy, such as for acute leukaemia, are offered an antibiotic tablet while their white cells are lowest,. Guidelines disagree on who should have it: NICE offers it to more adults; children's and Australian guidelines limit it to the highest risk, as it breeds resistant germs. It does not replace calling the team at once with a fever.

## Summary

Guidelines agree that prophylaxis is a fluoroquinolone given only for the period of severe neutropenia, and differ on who gets it. NICE CG151 offers fluoroquinolone prophylaxis to adults with acute leukaemias, stem cell transplants or solid tumours in whom a neutrophil count of 0.5 × 10⁹/L or lower is anticipated, noting that only ciprofloxacin was licensed for it in September 2024 and pointing to the MHRA January 2024 restrictions; units using it should monitor resistance. ASCO/IDSA (2018) recommend antibacterial prophylaxis for patients at high risk, including those expected to have profound, protracted neutropenia (under 100 neutrophils/µL for more than 7 days). For children, the international paediatric guideline (2020, endorsed by COG) says consider prophylaxis only in AML and relapsed ALL on intensive chemotherapy expected to cause neutrophils under 500/µL for at least 7 days (weak, high quality), not routinely in ALL induction or after autologous or allogeneic HSCT (weak), and not at all when severe neutropenia for 7 days is not expected (strong, moderate); levofloxacin is preferred (strong, moderate), ciprofloxacin an alternative with weaker gram-positive cover. Prophylaxis halved bacteraemia in children with AML or relapsed ALL but increased resistance and did not reduce overall mortality. The 2025 Australian and New Zealand consensus concludes that in most circumstances the harms outweigh the benefit.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: fluoroquinolone prophylaxis; levofloxacin prophylaxis; ciprofloxacin prophylaxis; antibiotic prophylaxis in neutropenia; neutropenic antibacterial prophylaxis
- Tags: protocol; antimicrobial-prophylaxis; paediatric

## Connected records

- protocols: [Antifungal prophylaxis for people at high risk of invasive fungal infection](https://onco.cc/protocols/antifungal-prophylaxis-in-haematology/), [Fever and neutropenia in children with cancer or after stem cell transplant](https://onco.cc/protocols/paediatric-fever-and-neutropenia/), [Suspected febrile neutropenia (neutropenic sepsis): the first hour](https://onco.cc/protocols/febrile-neutropenia-first-hour/)
- cancers: [Acute lymphoblastic leukaemia](https://onco.cc/cancers/all-leukemia/), [Acute myeloid leukaemia](https://onco.cc/cancers/aml/), [Childhood cancers (all types)](https://onco.cc/cancers/childhood-cancers/)
- fronts: [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- technologies: [Allogeneic stem cell transplantation](https://onco.cc/technologies/allogeneic-hsct/), [Autologous stem cell transplant (high-dose therapy)](https://onco.cc/technologies/autologous-stem-cell-transplant/)
- companies: [Children's Oncology Group (COG)](https://onco.cc/companies/childrens-oncology-group/)
- institutions: [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/), [National Institute for Health and Care Excellence](https://onco.cc/institutions/nice/)
- terms: [Febrile neutropenia](https://onco.cc/terms/febrile-neutropenia/), [Neutropenia](https://onco.cc/terms/neutropenia/)

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