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 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 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. |
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
