Infections after hematopoietic stem cell transplantation
From IDWiki
Timeline of Infections
| Time | Risk factors | 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
| 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. |
| Bordatella 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. | |
Antimicrobial prophylaxis
| Indication | Antimicrobial | Timing | GVHD |
|---|---|---|---|
| Bacterial infections with neutropenia >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 | (val)acyclovir | from conditioning until engraftment | no |
| VZV | (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: 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
