Infections after hematopoietic stem cell transplantation: Difference between revisions
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See also: |
See also: |
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+ | |||
− | * [[Conditioning regimens for HSCT]] |
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+ | *[[Conditioning regimens for HSCT]] |
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==Timeline of Infections== |
==Timeline of Infections== |
||
{| class="wikitable" |
{| class="wikitable" |
||
+ | ! rowspan="2" |Time |
||
− | ! Time !! Risk factors !! Bacteria !! Viruses !! Fungi !! Parasites |
||
+ | ! rowspan="2" |Risk factors |
||
+ | ! colspan="4" |Organisms |
||
|- |
|- |
||
+ | !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]] |
||
|- |
|- |
||
− | | |
+ | |'''Pre-engraftment'''<br />day 0 to 30 |
− | | |
+ | |Neutropenia, mucositis, and central lines |
+ | |GPCs and GNBs |
||
− | | GPCs, [[encapsulated bacteria]], [[Listeria]], [[Salmonella]], [[Nocardia]] |
||
− | | |
+ | |[[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 |
||
| |
| |
||
| |
| |
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==Prevention== |
==Prevention== |
||
+ | |||
+ | === Pre-Transplant Screening === |
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+ | |||
+ | * For autoHSCT: HBV, HCV, HEV, and HIV screening |
||
+ | |||
+ | === By Infection === |
||
{| class="wikitable" |
{| class="wikitable" |
||
− | ! |
+ | !Infection |
− | ! |
+ | !Preventing exposure |
− | ! |
+ | !Preventing disease |
|- |
|- |
||
− | ! colspan=3 | |
+ | ! 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 >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. |
|- |
|- |
||
− | | |
+ | |''[[Bordetella pertussis]]'' |
− | | |
+ | |Ensuring up-to-date immunizations of close contacts. |
− | | |
+ | |Immunization of all HCT recipients. Post-exposure prophylaxis if exposed. |
|- |
|- |
||
− | ! colspan=3 | |
+ | ! 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 | |
+ | ! 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. |
+ | |- |
||
+ | ! colspan="3" |Other infections |
||
+ | |- |
||
+ | |[[Mycobacterium tuberculosis]] |
||
+ | |Avoid exposure, including certain occupations |
||
+ | |Screen for and treat [[LTBI]] prior to transplant. Consider prophylaxis with INH post-transplant. |
||
+ | |- |
||
+ | |[[Toxoplasma gondii]] |
||
+ | |Provide education about decreasing risk. |
||
+ | |Pretransplant screening of IgG antibody (reactivation in 2 to 6% of those who are positive). Consider preemptive therapy or prophylaxis for high-risk (e.g. allogeneic HSCT) recipients; note that prophylaxis with [[TMP-SMX]] may already be indicated for [[Pneumocystis]], above. Not needed for autologous transplants. |
||
+ | |- |
||
+ | |[[Strongyloides stercoralis]] |
||
+ | |Avoid contact with outhouses and cutaneous exposure soil or human feces. |
||
+ | |High-risk patients should be screened for IgG antibodies and treated with [[ivermectin]] before transplantation. |
||
+ | |- |
||
+ | |[[Trypanosoma cruzi]] |
||
+ | |Pre-transplant screening of donor and recipient serostatus in those who were born in, received a transfusion in, or have ever lived at least 6 months in a Chagas-endemic area. Exclusion of positive donors. |
||
+ | |Seropositivity is not a contraindication to receiving transplant. |
||
+ | |- |
||
+ | |[[Plasmodium]] |
||
+ | |Exclusion of donors who have traveled to malaria-endemic area in past 1 year, or who have lived in an endemic area in past 3 years. If not feasible to wait, consider treating donor empirically before donation. |
||
+ | |Pre-transplant screening of recipients by blood smear, rapid test, or PCR. |
||
|} |
|} |
||
− | ===Antimicrobial |
+ | ===Antimicrobial Prophylaxis in AlloHSCT=== |
{| class="wikitable" |
{| class="wikitable" |
||
+ | ! rowspan="2" |Time |
||
− | ! Indication |
||
+ | ! colspan="3" |Organisms |
||
− | ! Antimicrobial |
||
− | ! Timing |
||
− | ! GVHD |
||
|- |
|- |
||
+ | !Bacteria |
||
− | | Bacterial infections with neutropenia >7 days |
||
+ | !Viruses |
||
− | | [[levofloxacin]] or other fluoroquinolone |
||
+ | !Fungi |
||
− | | from conditioning to engraftment |
||
− | | no |
||
|- |
|- |
||
+ | |'''Pre-engraftment'''<br />day 0 to 30 |
||
− | | Invasive [[pneumococcus]] |
||
− | | |
+ | |[[levofloxacin]] or other [[fluoroquinolone]] starting D+1 until engraftment (ANC>1 x3d) |
+ | |[[HSV]]-positive: ([[valacyclovir|val]])[[acyclovir]] |
||
− | | in chronic GVHD |
||
+ | [[VZV]]-positive: ([[valacyclovir|val]])[[acyclovir]] |
||
− | | yes |
||
+ | |||
+ | [[CMV]]-positive: [[valganciclovir]] or preemptive therapy (from day 10) |
||
+ | |[[fluconazole]] (or [[voriconazole]] or [[posaconazole]]) |
||
|- |
|- |
||
+ | |'''Early post-engraftment'''<br />to day 100 |
||
− | | Yeast infections |
||
+ | | |
||
− | | [[fluconazole]] (or [[voriconazole]] or [[posaconazole]]) |
||
+ | |[[VZV]]-positive: ([[valacyclovir|val]])[[acyclovir]] |
||
− | | from conditioning to engraftment, possibly longer |
||
+ | [[CMV]]-positive: [[valganciclovir]] or preemptive therapy |
||
− | | no |
||
+ | |[[fluconazole]] (or [[voriconazole]] or [[posaconazole]]) (to day 75-100 and off immunosuppression) |
||
+ | [[TMP-SMX]] for [[PJP]] |
||
|- |
|- |
||
+ | |'''Mid post-engraftment'''<br />to 1 year |
||
− | | Mold infections |
||
− | | [[posaconazole]] |
||
| |
| |
||
+ | |[[VZV]]-positive: ([[valacyclovir|val]])[[acyclovir]] |
||
− | | yes |
||
+ | |[[TMP-SMX]] for [[PJP]] (to 6 months) |
||
|- |
|- |
||
+ | |'''Late post-engraftment'''<br />after 1 year |
||
− | | [[HSV]] |
||
+ | | |
||
− | | ([[valacyclovir|val]])[[acyclovir]] |
||
+ | | |
||
− | | from conditioning until engraftment |
||
− | | |
+ | | |
|- |
|- |
||
+ | |'''GVHD''' |
||
− | | [[VZV]] |
||
+ | |[[levofloxacin]] or other [[fluoroquinolone]] for [[Streptococcus pneumoniae]] |
||
− | | ([[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 |
||
| |
| |
||
+ | |[[posaconazole]], [[TMP-SMX]] for [[PJP]] |
||
|} |
|} |
||
+ | |||
+ | === Autologous HSCT === |
||
+ | |||
+ | * Bacterial |
||
+ | ** Can consider [[levofloxacin]] prophylaxis, which decreases risk of infection but doesn't affect mortality |
||
+ | * Viral |
||
+ | ** Suggest [[acyclovir]] as [[HSV]]/[[VZV]] prophylaxis for at least 6 months |
||
+ | ** No role for [[CMV]] prophylaxis |
||
+ | ** Monitor for [[EBV]] reactivation, which is a concern |
||
+ | ** [[Tenofovir]] or [[entecavir]] as [[HBV]] prophylaxis in patients with positive HBsAg or HBcAb, with serial monitoring of HBV DNA |
||
+ | * Fungal |
||
+ | ** Can consider [[TMP-SMX]] prophylaxis for [[PJP]] for at least 3-6 months and until CD4 count is about 200 |
||
+ | ** No role for antifungal, but can consider until ANC over 1 for 3 days |
||
==Further Reading== |
==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] |
||
− | * |
+ | *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]] |
[[Category:Immunocompromised hosts]] |
Latest revision as of 11:42, 28 July 2023
See also:
Timeline of Infections
Time | Risk factors | Organisms | |||
---|---|---|---|---|---|
Bacteria | Viruses | Fungi | Parasites | ||
Pre-engraftment 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 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 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 after 1 year |
Immunosuppresing meds, chronic GVHD | Encapsulated bacteria, Listeria, Salmonella, Nocardia | VZV, CMV, respiratory/enteric viruses |
Prevention
Pre-Transplant Screening
- For autoHSCT: HBV, HCV, HEV, and HIV screening
By Infection
Infection | Preventing exposure | Preventing disease |
---|---|---|
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 >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. |
Bordetella pertussis | Ensuring up-to-date immunizations of close contacts. | Immunization of all HCT recipients. Post-exposure prophylaxis if exposed. |
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. |
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. | |
Other infections | ||
Mycobacterium tuberculosis | Avoid exposure, including certain occupations | Screen for and treat LTBI prior to transplant. Consider prophylaxis with INH post-transplant. |
Toxoplasma gondii | Provide education about decreasing risk. | Pretransplant screening of IgG antibody (reactivation in 2 to 6% of those who are positive). Consider preemptive therapy or prophylaxis for high-risk (e.g. allogeneic HSCT) recipients; note that prophylaxis with TMP-SMX may already be indicated for Pneumocystis, above. Not needed for autologous transplants. |
Strongyloides stercoralis | Avoid contact with outhouses and cutaneous exposure soil or human feces. | High-risk patients should be screened for IgG antibodies and treated with ivermectin before transplantation. |
Trypanosoma cruzi | Pre-transplant screening of donor and recipient serostatus in those who were born in, received a transfusion in, or have ever lived at least 6 months in a Chagas-endemic area. Exclusion of positive donors. | Seropositivity is not a contraindication to receiving transplant. |
Plasmodium | Exclusion of donors who have traveled to malaria-endemic area in past 1 year, or who have lived in an endemic area in past 3 years. If not feasible to wait, consider treating donor empirically before donation. | Pre-transplant screening of recipients by blood smear, rapid test, or PCR. |
Antimicrobial Prophylaxis in AlloHSCT
Time | Organisms | ||
---|---|---|---|
Bacteria | Viruses | Fungi | |
Pre-engraftment day 0 to 30 |
levofloxacin or other fluoroquinolone starting D+1 until engraftment (ANC>1 x3d) | HSV-positive: (val)acyclovir
CMV-positive: valganciclovir or preemptive therapy (from day 10) |
fluconazole (or voriconazole or posaconazole) |
Early post-engraftment to day 100 |
VZV-positive: (val)acyclovir
CMV-positive: valganciclovir or preemptive therapy |
fluconazole (or voriconazole or posaconazole) (to day 75-100 and off immunosuppression) | |
Mid post-engraftment to 1 year |
VZV-positive: (val)acyclovir | TMP-SMX for PJP (to 6 months) | |
Late post-engraftment after 1 year |
|||
GVHD | levofloxacin or other fluoroquinolone for Streptococcus pneumoniae | posaconazole, TMP-SMX for PJP |
Autologous HSCT
- Bacterial
- Can consider levofloxacin prophylaxis, which decreases risk of infection but doesn't affect mortality
- Viral
- Fungal
Further Reading
- Life-threatening Infection in Transplant Recipients. Crit Care Clin. 2013 Oct;29(4):953-73. doi: 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: 10.1016/j.bbmt.2009.06.019