Canterbury DHB

Context

Preventing Infections

The precautions described here often only apply when the neutrophil count is below 0.5 x109/L. Although this is a general rule, there are exceptions.

Allografts are at particular risk of infection, due to a combination of neutropenia and immunosuppression, a risk exacerbated by GvHD and its treatment.

In This Section

Low Bacterial Diet

Bacterial Infections

Hepatitis B Prevention

Herpetic Infections

Pneumocystis Prophylaxis

CMV Prevention

Fungal Infections

Influenza and Respiratory Illnesses

Toxoplasmosis Prophylaxis

Prevention of Infection Pre-splenectomy and in Splenic Atrophy

Low Bacterial Diet

A low bacterial diet should be commenced on admission and maintained regardless of blood counts until the whole intensive chemotherapy schedule has been completed. It should be continued until 6 weeks post-transplant for autologous BMT and at least 12 weeks post-transplant for allogeneic BMT – longer if significant graft versus host disease is present.

RIC patients require a low bacterial diet for 6 weeks or longer if significant GvHD. SCT recipients, and potential recipients should avoid sharing cups, glasses, and eating utensils with others, including family members. This is to decrease the risk of infections such as CMV, HSV, and EBV.

Bacterial Infections

Hepatitis B Prevention

Herpetic Infections

Patients receiving intensive chemotherapy

All SCT Patients

These are at highest risk of developing both herpes simplex and herpes zoster (VZV) infections.

Immunosuppressed patients who come into contact with chicken pox or shingles:

Pneumocystis Prophylaxis

Pneumocystis jiroveci (previously known as carinii) is an opportunistic pathogen whose natural habitat is the lung.

Pneumocystis can proliferate to cause pneumonia in those who are very immunosuppressed, particularly those with low CD4+ T-cells, either due to underlying disease or due to potent T-lymphocytotoxic treatments, such as purine analogues, intensive chemotherapy and anti T-cell antibodies. Therefore patients at particular risk include those with acute lymphoblastic lymphoma, severe aplastic anaemia, transplants – both allogeneic and autologous – and intensively-treated lymphoproliferative disorders.

Indications for pneumocystic prohpylaxis

Without tests for quantifying CD4+ numbers and function, we cannot be absolutely sure which patients are sufficiently immunosuppressed that they should receive prophylactic treatment, but the general approach to pneumocystis prophylaxis outlined below should be followed:

Medications for pneumocystis prophylaxis:

First line: trimethoprim + sulfamethoxazole 80 + 400 mg PO once daily.

If a patient does not tolerate this dose of trimethoprim + sulfamethoxazole, or if there is concern regarding the quality of engraftment, use a second or third line option as below until it is appropriate to resume trimethoprim + sulfamethoxazole.

Second line: Pentamidine 4 mg/kg IV 4 weekly. Dose is usually capped at 300 mg. Pentamidine is manufactured at a concentration of 2 mg/mL, in dextrose 5% or sodium chloride 0.9%, and is given over 2 hours. The HIV data indicates that if the period is extended beyond 4 weeks, protection is inadequate.

Third line: Dapsone 100 mg PO daily.

Due to the interaction between methotrexate and trimethoprim + sulfamethoxazole, patients receiving high dose methotrexate concurrently should have pentamidine as first line pnemocystis prophylaxis.

Pentamidine must be charted on the pentamidine prescription chart. If an inpatient, this should also be charted on MedChart as ‘infusion chart exists’ (i.e., as a dummy drug) with the qualifier ‘pentamidine’ so there is an electronic record. Administration of pentamidine should also be included on the discharge summary. The pentamidine chart is then filed in the outpatient notes on discharge for future administrations.

See information about Treatment of Pneumocystis.

About this Canterbury DHB document (9471):

Document Owner:

Ruth Spearing and Sarah Metcalfe (see Who's Who)

Issue Date:

November 2016

Next Review:

November 2018

Keywords:

Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer

Topic Code: 9471