View source for Infections after hematopoietic stem cell transplantation

==Timeline of Infections==

{| class="wikitable"
! Time !! Risk factors !! Bacteria !! Viruses !! Fungi !! Parasites
|-
| '''Pre-engraftment'''<br/>day 0 to 30
| Neutropenia, mucositis, and central lines
| GPCs and GNBs
| [[BK virus]], [[HSV]], and resp/enteric viruses
| [[Candida]] and [[Aspergillus]]
| [[Strongyloides]]
|-
| '''Early post-engraftment'''<br/>to day 100
| Immunosuppressing meds, acute GVHD, central lines
| GPCs, [[encapsulated bacteria]], [[Listeria]], [[Salmonella]], [[Nocardia]]
| [[HSV]], [[CMV]], [[HHV-6]], [[adenovirus]], resp/enteric viruses
| [[Aspergillus]], other [[molds]], [[PJP]]
| [[Strongyloides]], [[Toxoplasma]]
|-
| '''Mid post-engraftment'''<br/>to 1 year
| Immunosuppressing meds, chronic GVHD
| [[Encapsulated bacteria]], [[Listeria]], [[Salmonella]], [[Nocardia]]
| [[VZV]], [[EBV]] (and [[PTLD]]), [[CMV]], respiratory/enteric viruses
| [[Aspergillus]], other [[molds]], [[PJP]]
| 
|-
| '''Late post-engraftment'''<br/>after 1 year
| Immunosuppresing meds, chronic GVHD
| [[Encapsulated bacteria]], [[Listeria]], [[Salmonella]], [[Nocardia]]
| [[VZV]], [[CMV]], respiratory/enteric viruses
|
|
|}

==Prevention==
{| class="wikitable"
! Infection
! Preventing exposure
! Preventing disease
|-
! colspan=3 | Bacterial infections
|-
| Early disease (0-100 days after HCT)
| 
| Use [[levofloxacin]] or other respiratory fluoroquinolone in adult patients with anticipated neutropenia of 7 or more days until recovery of neutropenia. GM-CSF or G-CSF may decrease risk of infection, but unclear if it decreases mortality.
|-
| Late disease (100 days after HCT)
| 
| Antibiotic prophylaxis is indicated for alloHSCT recipients with [[chronic GVHD]] to prevent invasive [[pneumococcal]] disease until cGVHD resolves.
|-
| [[CLABSI]]
| Implement a CLABSI bundle to ensure maximum sterility on insertion.
| If infection rate is still &gt;1 per 1000 catheter days, can consider prophylactic [[minocycline]] plus [[rifampin]].
|-
| ''[[Streptococcus pneumoniae]]''
| Routine precautions.
| Immunization for all HCT recipients. Antibiotic prophylaxis for [[chronic GVHD]] and for low IgG levels, regardless of vaccination status, usually with [[penicillin]].
|-
| [[Viridans group streptococci]]
| 
| Pre-conditioning dental consults.
|-
| ''[[Haemophilus influenzae]]'' type b
| Ensuring up-to-date immunizations of close contacts.
| Immunization of all HCT recipients. Post-exposure prophylaxis if exposed.
|-
| ''[[Bordatella pertussis]]''
| Ensuring up-to-date immunizations of close contacts.
| Immunization of all HCT recipients. Post-exposure prophylaxis if exposed.
|-
! colspan=3 | Viral infections
|-
| [[Cytomegalovirus]]
| Pre-transplant screening of donor and recipient IgG serostatus.
| All R+ or D+ recipients should have either prophylaxis or close monitoring with preemptive treatment until at least day 100. Monitoring should start on day 10 and continue weekly until at least day 100.
|-
| [[Epstein-Barr virus]], especially PTLD
| Pre-transplant screening of donor and recipient IgG serostatus, especially in children.
| Monitor high-risk recipients (T-cell depletion, ant-T-cell antibodies, umbilical cord transplants, and haplo-identical transplants), with reduction in immunosuppression if rising viral load.
|-
| [[Herpes simplex virus]]
| Pre-transplant screening of donor and recipient IgG serostatus. Counselling of seronegative recipients on protective behaviours.
| [[Acyclovir]] for all seropositive recipients of alloHSCT from conditioning until engraftment (about 30 days). Not necessary if receiving prophylaxis for CMV.
|-
| [[Varicella zoster virus]]
| Pre-transplant screening of donor and recipient IgG serostatus. Close contacts should have up-to-date vaccinations before visiting.
| [[Acyclovir]] or [[valacyclovir]] for all seropositive recipients of alloHSCT from conditioning until 1 year and during chronic GVHD. Post-exposure prophylaxis with VariZIG for seronegative recipients.
|-
| [[Influenza]]
| Annual immunization of recipient and close contacts.
| Consider prophylaxis of recipient and possibly also close contacts during outbreaks.
|-
| [[Adenovirus]]
| 
| Weekly screening PCR for the first 6 months and during severe immunosuppression.
|-
| [[Hepatitis B virus]]
| Pre-transplant screening of donor and recipient serostatus. Immunization of seronegative recipients.
| Monitoring ALT during prolonged corticosteroid use with HBV DNA viral load if ALT is elevated, and pre-emptive antiviral therapy if the viral load is positive. Consider prophylaxis for anti-HBc-positive recipients from conditioning to 6 months after transplant. Monitor anti-HBs titres every 3 months, with viral load if it is decreasing. Re-immunize if titres become negative. Treatment of choice is [[lamivudine]] 100 mg/day.
|-
| [[Hepatitis C virus]]
| Pre-transplant screening of donor and recipient serostatus with viral load if positive or if at elevated risk despite negative serology.
| For those with HCV, consider liver biopsy if iron overloaded, alcohol abuse, HCV for longer than 10 years, or clinical evidence of chronic liver disease. Consider treatment after 2 years post-transplant if without GVHD and no immunosuppressing medications for at least 6 months.
|-
! colspan=3 | Fungal infections
|-
| Yeasts, especially ''[[Candida]]''
|
| [[Fluconazole]] or a mold-active azole from conditioning until engraftment, and possibly to day 75.
|-
| Molds, especially ''[[Aspergillus]]''
| Appropriate IPAC practices, including positive-pressure ventilation in recipient rooms.
| Unclear role for prophylaxis, though can use [[posaconazole]] during GVHD.
|-
| ''[[Pneumocystis jirovecii]]''
| 
| [[TMP-SMX]] in recipients of alloHSCT from engraftment until 6 months after transplant.
|}

===Antimicrobial prophylaxis===
{| class="wikitable"
! Indication
! Antimicrobial
! Timing
! GVHD
|-
| Bacterial infections with neutropenia &gt;7 days
| [[levofloxacin]] or other fluoroquinolone
| from conditioning to engraftment
| no
|-
| Invasive [[pneumococcus]]
| [[levofloxacin]] or other fluoroquinolone
| in chronic GVHD
| yes
|-
| Yeast infections
| [[fluconazole]] (or [[voriconazole]] or [[posaconazole]])
| from conditioning to engraftment, possibly longer
| no
|-
| Mold infections
| [[posaconazole]]
|
| yes
|-
| [[HSV]]
| ([[valacyclovir|val]])[[acyclovir]]
| from conditioning until engraftment
| no
|-
| [[VZV]]
| ([[valacyclovir|val]])[[acyclovir]]
| from conditioning until 1 year
| yes
|-
| [[CMV]]
| preemptive therapy or [[valganciclovir]]
| from day 10 to early postengraftment (day 100)
| no
|-
| [[Pneumocystis]]
| [[TMP-SMX]]
| from engraftment to 6 months
|
|}

==Further Reading==
* Life-threatening Infection in Transplant Recipients. ''Crit Care Clin''. 2013 Oct;29(4):953-73. doi: [https://doi.org/10.1016/j.ccc.2013.06.012 10.1016/j.ccc.2013.06.012]
* Guidelines for Preventing Infectious Complications among Hematopoietic Cell Transplantation Recipients: A Global Perspective. ''Biol Blood Marrow Transplant''. 2009;15:1143-1238. doi: [https://doi.org/10.1016/j.bbmt.2009.06.019 10.1016/j.bbmt.2009.06.019]

[[Category:Immunocompromised hosts]]