ibritumomab tiuxetan
Dosage Form: injection
FULL PRESCRIBING INFORMATION
Serious Infusion Reactions: Deaths have occurred within 24 hours of rituximab infusion, an essential component of the Zevalin therapeutic regimen. These fatalities were associated with hypoxia, pulmonary infiltrates, acute respiratory distress syndrome, myocardial infarction, ventricular fibrillation, or cardiogenic shock. Most (80%) fatalities occurred with the first rituximab infusion [see Warnings and Precautions (5.1) and Adverse Reactions (6.1)]. Discontinue rituximab and Y-90 Zevalin infusions in patients who develop severe infusion reactions.
Prolonged and Severe Cytopenias: Y-90 Zevalin administration results in severe and prolonged cytopenias in most patients. Do not administer Y-90 Zevalin to patients with ≥ 25% lymphoma marrow involvement and/or impaired bone marrow reserve [see Warnings and Precautions (5.2) and Adverse Reactions (6.1)].
Severe Cutaneous and Mucocutaneous Reactions: Severe cutaneous and mucocutaneous reactions, some fatal, can occur with the Zevalin therapeutic regimen. Discontinue rituximab and Y-90 Zevalin infusions in patients experiencing severe cutaneous or mucocutaneous reactions [see Warnings and Precautions (5.3) and Adverse Reactions (6.3)].
Dosing: The dose of Y-90 Zevalin should not exceed 32.0 mCi (1184 MBq) [see Dosage and Administration (2.2)].
Indications and Usage for Zevalin
Relapsed or Refractory, Low-grade or Follicular NHL
Zevalin is indicated for the treatment of relapsed or refractory, low-grade or follicular B-cell non-Hodgkin's lymphoma (NHL).
Previously Untreated Follicular NHL
Zevalin is indicated for the treatment of previously untreated follicular NHL in patients who achieve a partial or complete response to first-line chemotherapy.
Zevalin Dosage and Administration
Recommended Dosing Schedule:
- Administer the Zevalin therapeutic regimen as outlined in Section 2.1.
- Initiate the Zevalin therapeutic regimen following recovery of platelet counts to ≥150,000/mm3 at least 6 weeks, but no more than 12 weeks, following the last dose of first-line chemotherapy.
Overview of Dosing Schedule
Zevalin Therapeutic Regimen Dosage and Administration
Day 1:
- Premedicate with acetaminophen 650 mg orally and diphenhydramine 50 mg orally prior to rituximab infusion.
- Administer rituximab 250 mg/m2 intravenously at an initial rate of 50 mg/hr. In the absence of infusion reactions, escalate the infusion rate in 50 mg/hr increments every 30 minutes to a maximum of 400 mg/hr. Do not mix or dilute rituximab with other drugs.
- Immediately stop the rituximab infusion for serious infusion reactions and discontinue the Zevalin therapeutic regimen [see Boxed Warning and Warnings and Precautions (5.1)].
- Temporarily slow or interrupt the rituximab infusion for less severe infusion reactions. If symptoms improve, continue the infusion at one-half the previous rate.
Day 7, 8 or 9:
- Premedicate with acetaminophen 650 mg orally and diphenhydramine 50 mg orally prior to rituximab infusion.
- Administer rituximab 250 mg/m2 intravenously at an initial rate of 100 mg/hr. Increase rate by 100 mg/hr increments at 30 minute intervals, to a maximum of 400 mg/hr, as tolerated. If infusion reactions occurred during rituximab infusion on Day 1 of treatment, administer rituximab at an initial rate of 50 mg/hr and escalate the infusion rate in 50 mg/hr increments every 30 minutes to a maximum of 400 mg/hr.
- Administer Y-90 Zevalin injection through a free flowing intravenous line within 4 hours following completion of rituximab infusion. Use a 0.22 micron low-protein-binding in-line filter between the syringe and the infusion port. After injection, flush the line with at least 10 mL of normal saline.
- If platelet count ≥ 150,000/mm3, administer Y-90 Zevalin over 10 minutes as an intravenous injection at a dose of Y-90 0.4 mCi per kg (14.8 MBq per kg) actual body weight.
- If platelet count ≥ 100,000 but ≤149,000/mm3, in relapsed or refractory patients, administer Y-90 Zevalin over 10 minutes as an intravenous injection at a dose of Y-90 0.3 mCi per kg (11.1 MBq per kg) actual body weight.
- Do not administer more than 32 mCi (1184 MBq) Y-90 Zevalin dose regardless of the patient’s body weight.
- Monitor patients closely for evidence of extravasation during the injection of Y-90 Zevalin. Immediately stop infusion and restart in another limb if any signs or symptoms of extravasation occur [see Warnings and Precautions (5.7)].
Directions for Preparation of Radiolabeled Y-90 Zevalin Doses
A clearly-labeled kit is required for preparation of Yttrium-90 (Y-90) Zevalin. Follow the detailed instructions for the preparation of radiolabeled Zevalin [see Dosage and Administration (2.4)].
Required materials not supplied in the kit:
- Yttrium-90 Chloride Sterile Solution
- Three sterile 1 mL plastic syringes
- One sterile 3 mL plastic syringe
- Two sterile 10 mL plastic syringes with 18-20 G needles
- ITLC silica gel strips
- 0.9% Sodium Chloride aqueous solution for the chromatography solvent
- Developing chamber for chromatography
- Suitable radioactivity counting apparatus
- Filter, 0.22 micrometer, low-protein-binding
- Appropriate acrylic shielding for reaction vial and syringe for Y-90
Method:
- Allow contents of the refrigerated Y-90 Zevalin kit (Zevalin vial, 50 mM sodium acetate vial, and formulation buffer vial) to reach room temperature.
- Place the empty reaction vial in an appropriate acrylic shield.
- Determine the amount of each component needed:
- Calculate volume of Y-90 Chloride equivalent to 40 mCi based on the activity concentration of the Y-90 Chloride stock.
- The volume of 50 mM Sodium Acetate solution needed is 1.2 times the volume of Y-90 Chloride solution determined in step 3.a, above.
- Calculate the volume of formulation buffer needed to bring the reaction vial contents to a final volume of 10 mL.
- Transfer the calculated volume of 50 mM Sodium Acetate to the empty reaction vial. Coat the entire inner surface of the reaction vial by gentle inversion or rolling.
- Transfer 40 mCi of Y-90 Chloride to the reaction vial using an acrylic shielded syringe. Mix the two solutions by gentle inversion or rolling.
- Transfer 1.3 mL of Zevalin (ibritumomab tiuxetan) to the reaction vial. Do not shake or agitate the vial contents.
- Allow the labeling reaction to proceed at room temperature for 5 minutes. A shorter or longer reaction time may adversely alter the final labeled product.
- Immediately after the 5-minute incubation period, transfer the calculated volume of formulation buffer from step 3.c. to the reaction vial. Gently add the formulation buffer down the side of the reaction vial. If necessary, withdraw an equal volume of air to normalize pressure.
- Measure the final product for total activity using a radioactivity calibration system suitable for the measurement of Y-90.
- Using the supplied labels, record the date and time of preparation, the total activity and volume, and the date and time of expiration, and affix these labels to the shielded reaction vial container.
- Patient Dose: Calculate the volume required for a Y-90 Zevalin dose [see Dosage and Administration (2.2)]. Withdraw the required volume from the reaction vial. Assay the syringe in the dose calibrator suitable for the measurement of Y-90. The measured dose must be within 10% of the prescribed dose of Y-90 Zevalin and must not exceed 32 mCi (1184 MBq). Using the supplied labels, record the patient identifier, total activity and volume and the date and time of expiration, and affix these labels to the syringe and shielded unit dose container.
- Determine Radiochemical Purity [see Dosage and Administration (2.4)].
- Store Yttrium-90 Zevalin at 2-8°C (36-46°F) until use and administer within 8 hours of radiolabeling. Immediately prior to administration, assay the syringe and contents using a radioactivity calibration system suitable for the measurement of Y-90.
Procedure for Determining Radiochemical Purity
Use the following procedures for radiolabeling Y-90 Zevalin:
- Place a small drop of Y-90 Zevalin at the origin of an ITLC silica gel strip.
- Place the ITLC silica gel strip into a chromatography chamber with the origin at the bottom and the solvent front at the top. Allow the solvent (0.9% NaCl) to migrate at least 5 cm from the bottom of the strip. Remove the strip from the chamber and cut the strip in half. Count each half of the ITLC silica gel strip for one minute (CPM) with a suitable counting apparatus.
- Calculate the percent RCP as follows:
- Repeat the ITLC procedure if the radiochemical purity is <95%. If repeat testing confirms that radiochemical purity is <95%, do not administer the Y-90 Zevalin dose.
Radiation Dosimetry
During clinical trials with Zevalin, estimations of radiation-absorbed doses for Y-90 Zevalin were performed using sequential whole body images and the MIRDOSE 3 software program. The estimated radiation absorbed doses to organs and marrow from a course of the Zevalin therapeutic regimen are summarized in Table 1. Absorbed dose estimates for the lower large intestine, upper large intestine, and small intestine have been modified from the standard MIRDOSE 3 output to account for the assumption that activity is within the intestine wall rather than the intestine contents.
| ||
| Organ | Y-90 Zevalin cGy /mCi (mGy/MBq) | |
| Median | Range | |
| Spleen* | 34.78 (9.4) | 6.66 - 74.00 (1.8 - 20.0) |
| Liver* | 17.76 (4.8) | 10.73 - 29.97 (2.9 - 8.1) |
| Lower Large Intestinal Wall* | 17.39 (4.7) | 11.47 - 30.34 (3.1 - 8.2) |
| Upper Large Intestinal Wall* | 13.32 (3.6) | 7.40 - 24.79 (2.0 - 6.7) |
| Heart Wall* | 10.73 (2.9) | 5.55 - 11.84 (1.5 - 3.2) |
| Lungs* | 7.4 (2) | 4.44 - 12.58 (1.2 -3.4) |
| Testes* | 5.55 (1.5) | 3.70 - 15.91 (1.0 - 4.3) |
| Small Intestine* | 5.18 (1.4) | 2.96 - 7.77 (0.8 - 2.1) |
| Red Marrow† | 4.81 (1.3) | 2.22 - 6.66 (0.6 - 1.8) |
| Urinary Bladder Wall‡ | 3.33 (0.9) | 2.59 - 4.81 (0.7 - 1.3) |
| Bone Surfaces† | 3.33 (0.9) | 1.85 - 4.44 (0.5 - 1.2) |
| Total Body‡ | 1.85 (0.5) | 1.48 - 2.59 (0.4 - 0.7) |
| Ovaries‡ | 1.48 (0.4) | 1.11 - 1.85 (0.3 - 0.5) |
| Uterus‡ | 1.48 (0.4) | 1.11 - 1.85 (0.3 - 0.5) |
| Adrenals‡ | 1.11 (0.3) | 0.74 - 1.85 (0.2 - 0.5) |
| Brain‡ | 1.11 (0.3) | 0.74 - 1.85 (0.2 - 0.5) |
| Breasts‡ | 1.11 (0.3) | 0.74 - 1.85 (0.2 - 0.5) |
| Gallbladder Wall‡ | 1.11 (0.3) | 0.74 - 1.85 (0.2 - 0.5) |
| Muscle‡ | 1.11 (0.3) | 0.74 - 1.85 (0.2 - 0.5) |
| Pancreas‡ | 1.11 (0.3) | 0.74 - 1.85 (0.2 - 0.5) |
| Skin‡ | 1.11 (0.3) | 0.74 - 1.85 (0.2 - 0.5) |
| Stomach‡ | 1.11 (0.3) | 0.74 - 1.85 (0.2 - 0.5) |
| Thymus‡ | 1.11 (0.3) | 0.74 - 1.85 (0.2 - 0.5) |
| Thyroid‡ | 1.11 (0.3) | 0.74 - 1.85 (0.2 - 0.5) |
| Kidneys* | 0.37 (0.1) | 0.00 - 1.11 (0.0 - 0.3) |
Dosage Forms and Strengths
3.2 mg ibritumomab tiuxetan per 2 mL, single-use vial.
Contraindications
None.
Warnings and Precautions
Serious Infusion Reactions
See also prescribing information for rituximab.
Rituximab, alone or as a component of the Zevalin therapeutic regimen, can cause severe, including fatal, infusion reactions. These reactions typically occur during the first rituximab infusion with time to onset of 30 to 120 minutes. Signs and symptoms of severe infusion reactions may include urticaria, hypotension, angioedema, hypoxia, bronchospasm, pulmonary infiltrates, acute respiratory distress syndrome, myocardial infarction, ventricular fibrillation, and cardiogenic shock. Temporarily slow or interrupt the rituximab infusion for less severe infusion reactions. Immediately discontinue rituximab and Y-90 Zevalin administration for severe infusion reactions [see Boxed Warning and Dosage and Administration (2.2)].
Prolonged and Severe Cytopenias
Cytopenias with delayed onset and prolonged duration, some complicated by hemorrhage and severe infection, are the most common severe adverse reactions of the Zevalin therapeutic regimen. When used according to recommended doses, the incidences of severe thrombocytopenia and neutropenia are greater in patients with mild baseline thrombocytopenia (100,000 to 149,000 /mm3) compared to those with normal pretreatment platelet counts. Severe cytopenias persisting more than 12 weeks following administration can occur [see Boxed Warning and Adverse Reactions (6.1)].
Do not administer the Zevalin therapeutic regimen to patients with ≥ 25% lymphoma marrow involvement and/or impaired bone marrow reserve. Monitor patients for cytopenias and their complications (e.g., febrile neutropenia, hemorrhage) for up to 3 months after use of the Zevalin therapeutic regimen. Avoid using drugs which interfere with platelet function or coagulation following the Zevalin therapeutic regimen.
Severe Cutaneous and Mucocutaneous Reactions
Erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, bullous dermatitis, and exfoliative dermatitis, some fatal, were reported in post-marketing experience. The time to onset of these reactions was variable, ranging from a few days to 4 months after administration of the Zevalin therapeutic regimen. Discontinue the Zevalin therapeutic regimen in patients experiencing a severe cutaneous or mucocutaneous reaction [see Boxed Warning and Adverse Reactions (6.3)].
Altered Biodistribution
In a post-marketing registry designed to collect biodistribution images and other information in reported cases of altered biodistribution, there were 12 (1.3%) patients reported to have altered biodistribution among 953 patients registered.
Leukemia and Myelodysplastic Syndrome
Myelodysplastic syndrome (MDS) and/or acute myelogenous leukemia (AML) were reported in 5.2% (11/211) of patients with relapsed or refractory NHL enrolled in clinical studies and 1.5% (8/535) of patients included in the expanded-access trial, with median follow-up of 6.5 and 4.4 years, respectively. Among the 19 reported cases, the median time to the diagnosis of MDS or AML was 1.9 years following treatment with the Zevalin therapeutic regimen; however, the cumulative incidence continues to increase [see Adverse Reactions (6.1)].
Among 204 patients receiving Y-90 Zevalin following first-line chemotherapy, two patients (1%) were diagnosed with AML within 3 years of receiving Zevalin.
Embryo-Fetal Toxicity
Based on its radioactivity, Y-90 Zevalin may cause fetal harm when administered to a pregnant woman. If the Zevalin therapeutic regimen is administered during pregnancy, the patient should be apprised of the potential hazard to a fetus. Advise women of childbearing potential to use adequate contraception for a minimum of twelve months [see Use in Specific Populations (8.1), Nonclinical Toxicology (13.1), and Patient Counseling Information (17)]].
Extravasation
Monitor patients closely for evidence of extravasation during Zevalin infusion. Immediately terminate the infusion if signs or symptoms of extravasation occur and restart in another limb [see Dosage and Administration (2.2)].
Immunization
The safety of immunization with live viral vaccines following the Zevalin therapeutic regimen has not been studied. Do not administer live viral vaccines to patients who have recently received Zevalin. The ability to generate an immune response to any vaccine following the Zevalin therapeutic regimen has not been studied.
Laboratory Monitoring
Monitor complete blood counts (CBC) and platelet counts following the Zevalin therapeutic regimen weekly until levels recover or as clinically indicated.
Radionuclide Precautions
During and after radiolabeling Zevalin with Y-90, minimize radiation exposure to patients and to medical personnel, consistent with institutional good radiation safety practices and patient management procedures.
Creutzfeldt-Jakob Disease (CJD)
The Zevalin therapeutic regimen contains albumin, a derivative of human blood. Based on effective donor screening and product manufacturing processes, Zevalin carries an extremely remote risk for transmission of viral diseases. A theoretical risk for transmission of Creutzfeldt-Jakob disease (CJD) also is considered extremely remote. No cases of transmission of viral diseases or CJD have ever been identified for albumin.
Adverse Reactions
The following serious adverse reactions are discussed in greater detail in other sections of the label:
- Serious Infusion Reactions [see Boxed Warning and Warnings and Precautions (5.1)].
- Prolonged and Severe Cytopenias [see Boxed Warning and Warnings and Precautions (5.2)].
- Severe Cutaneous and Mucocutaneous Reactions [see Boxed Warning and Warnings and Precautions (5.3)].
- Leukemia and Myelodysplastic Syndrome [see Warnings and Precautions (5.5)].
The most common adverse reactions of Zevalin are cytopenias, fatigue, nasopharyngitis, nausea, abdominal pain, asthenia, cough, diarrhea, and pyrexia.
The most serious adverse reactions of Zevalin are prolonged and severe cytopenias (thrombocytopenia, anemia, lymphopenia, neutropenia) and secondary malignancies.
Because the Zevalin therapeutic regimen includes the use of rituximab, see prescribing information for rituximab.
Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
The reported safety data reflects exposure to Zevalin in 349 patients with relapsed or refractory, low-grade, follicular or transformed NHL across 5 trials (4 single arm and 1 randomized) and in 206 patients with previously untreated follicular NHL in a randomized trial (Study 4) who received any portion of the Zevalin therapeutic regimen. The safety data reflect exposure to Zevalin in 270 patients with relapsed or refractory NHL with platelet counts ≥150,000/ mm3 who received 0.4 mCi/kg (14.8 MBq/kg) of Y-90 Zevalin (Group 1 in Table 4), 65 patients with relapsed or refractory NHL with platelet counts of 100,000 to 149,000/mm3 who received 0.3 mCi/kg (11.1 MBq/kg) of Y-90 Zevalin (Group 2 in Table 4), and 204 patients with previously untreated NHL with platelet counts ≥150,000/ mm3 who received 0.4 mCi/kg (14.8 MBq/kg) of Y-90 Zevalin; all patients received a single course of Zevalin.
Table 2 displays selected adverse reaction incidence rates in patients who received any portion of the Zevalin therapeutic regimen (n=206) or no further therapy (n=203) following first-line chemotherapy (Study 4).
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| Zevalin (n=206) | Observation (n=203) | |||
| All Grades† | Grade† 3-4 | All Grades† | Grade† 3-4 | |
| % | % | % | % | |
| Gastrointestinal Disorders | ||||
| Abdominal pain | 17 | 2 | 13 | <1 |
| Diarrhea | 11 | 0 | 3 | 0 |
| Nausea | 18 | 0 | 2 | 0 |
| Body as a Whole | ||||
| Asthenia | 15 | 1 | 8 | <1 |
| Fatigue | 33 | 1 | 9 | 0 |
| Influenza-like illness | 8 | 0 | 3 | 0 |
| Pyrexia | 10 | 3 | 4 | 0 |
| Musculoskeletal | ||||
| Myalgia | 9 | 0 | 3 | 0 |
| Metabolism | ||||
| Anorexia | 8 | 0 | 2 | 0 |
| Respiratory, Thoracic & Media | ||||
| Cough | 11 | <1 | 5 | 0 |
| Pharyngolaryngeal pain | 7 | 0 | 2 | 0 |
| Epistaxis | 5 | 2 | <1 | 0 |
| Nervous System | ||||
| Dizziness | 7 | 0 | 2 | 0 |
| Vascular | ||||
| Hypertension | 7 | 3 | 2 | <1 |
| Skin & Subcutaneous | ||||
| Night sweats | 8 | 0 | 2 | 0 |
| Petechiae | 8 | 2 | 0 | 0 |
| Pruritus | 7 | 0 | 1 | 0 |
| Rash | 7 | 0 | <1 | 0 |
| Infections & Infestations | ||||
| Bronchitis | 8 | 0 | 3 | 0 |
| Nasopharyngitis | 19 | 0 | 10 | 0 |
| Rhinitis | 8 | 0 | 2 | 0 |
| Sinusitis | 7 | <1 | <1 | 0 |
| Urinary tract infection | 7 | <1 | 3 | 0 |
| Blood and Lymphatic System | ||||
| Thrombocytopenia | 62 | 51 | 1 | 0 |
| Neutropenia | 45 | 41 | 3 | 2 |
| Anemia | 22 | 5 | 4 | 0 |
| Leukopenia | 43 | 36 | 4 | 1 |
| Lymphopenia | 26 | 18 | 9 | 5 |
Table 3 shows hematologic toxicities in 349 Zevalin-treated patients with relapsed or refractory, low-grade, follicular or transformed B-cell NHL. Grade 2-4 hematologic toxicity occurred in 86% of Zevalin-treated patients.
| ||
All Grades % | Grade 3-4 % | |
| Thrombocytopenia | 95 | 63 |
| Neutropenia | 77 | 60 |
| Anemia | 61 | 17 |
| Ecchymosis | 7 | <1 |
Prolonged and Severe Cytopenias
Patients in clinical studies were not permitted to receive hematopoietic growth factors beginning 2 weeks prior to administration of the Zevalin therapeutic regimen.
The incidence and duration of severe hematologic toxicity in previously treated NHL patients (N=335) and in previously untreated patients (Study 4) receiving Y-90 Zevalin are shown in Table 4.
| |||
| Baseline Platelet Count | Group 1 (n=270) ≥ 150,000/mm3 | Group 2 (n=65 ) 100,000 to 149,000/mm3 | Study 4 (n=204) ≥ 150,000/mm3 |
| Y-90 Zevalin Dose | 0.4 mCi/kg (14.8 MBq/kg) | 0.3 mCi/kg (11.1 MBq/kg) | 0.4 mCi/kg (14.8 MBq/kg) |
| ANC | |||
| Median nadir ( per mm3) | 800 | 600 | 721 |
Per Patient Incidence ANC <1000/mm3 | 57% | 74% | 65% |
Per Patient Incidence ANC <500/mm3 | 30% | 35% | 26% |
Median Duration (Days)* ANC <1000/mm3 | 22 | 29 | 29 |
| Median Time to Recovery† | 12 | 13 | 15 |
| Platelets | |||
| Median nadir (per mm3) | 41,000 | 24,000 | 42,000 |
Per Patient Incidence Platelets <50,000/mm3 | 61% | 78% | 61% |
Per Patient Incidence Platelets <10,000/mm3 | 10% | 14% | 4% |
Median Duration (Days)‡ Platelets <50,000/mm3 | 24 | 35 | 26 |
| Median Time to Recovery† | 13 | 14 | 14 |
Cytopenias were more severe and more prolonged among eleven (5%) patients who received Zevalin after first-line fludarabine or a fludarabine-containing chemotherapy regimen as compared to patients receiving non-fludarabine-containing regimens. Among these eleven patients, the median platelet nadir was 13,000/mm3 with a median duration of platelets below 50,000/mm3 of 56 days and the median time for platelet recovery from nadir to Grade 1 toxicity or baseline was 35 days. The median ANC was 355/mm3, with a median duration of ANC below 1,000/mm3 of 37 days and the median time for ANC recovery from nadir to Grade 1 toxicity or baseline was 20 days.
The median time to cytopenia was similar across patients with relapsed/refractory NHL and those completing first-line chemotherapy, with median ANC nadir at 61-62 days, platelet nadir at 49-53 days, and hemoglobin nadir at 68-69 days after Y-90-Zevalin administration.
Information on hematopoietic growth factor use and platelet transfusions is based on 211 patients with relapsed/refractory NHL and 206 patients following first-line chemotherapy. Filgrastim was given to 13% of patients and erythropoietin to 8% with relapsed or refractory disease; 14% of patients receiving Zevalin following first-line chemotherapy received granulocyte-colony stimulating factors and 5% received erythopoiesis-stimulating agents. Platelet transfusions were given to approximately 22% of all Zevalin-treated patients. Red blood cell transfusions were given to 20% of patients with relapsed or refractory NHL and 2% of patients receiving Zevalin following first-line chemotherapy.
Infections
In relapsed or refractory NHL patients, infections occurred in 29% of 349 patients during the first 3 months after initiating the Zevalin therapeutic regimen and 3% developed serious infections (urinary tract infection, febrile neutropenia, sepsis, pneumonia, cellulitis, colitis, diarrhea, osteomyelitis, and upper respiratory tract infection). Life-threatening infectio
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