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Managing Infection in Cancer Patients and Other Immunocompromised Children

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Managing Infection in Cancer Patients and Other Immunocompromised Children The Ochsner Journal 12:202–210, 2012 Ó Academic Division of Ochsner Clinic Foundation Managing Infection in Cancer Patients and Other Immunocompromised Children Russell W. Steele, MD Division of Infectious Diseases, Department of Pediatrics, Ochsner Clinic Foundation, New Orleans, LA The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA bial therapy is used for defined infections, the use of the ABSTRACT highest dosages considered safe and longer durations are Children on immunosuppressive therapy for cancer or organ warranted. transplantation are very similar to those with primary immunodeficiency in that all are highly predisposed to infection with all types of pathogens—ie, bacteria, viruses, fungi, and parasites—and are highly likely to experience the reactivation INTRODUCTION of microbial agents, particularly viruses, while they are Oncology patients, both children and adults, have immunosuppressed. For this reason, early recognition and a very high incidence of infection, resulting from the treatment are critical for optimal chances of survival and immunodeficiency that is iatrogenically introduced 1,2 minimal morbidity. The selection of initial empiric therapy for during their management (Table 1). This circum- these patients when febrile is based on the type of immune stance is an unavoidable consequence of advances suppression (eg, neutropenia and cellular immunity) and other in cancer treatment that have resulted in greatly predisposing factors such as the presence of central venous increased survival and overall cure. Chemotherapeu- lines (CVLs). Much of our clinical approach to prophylactic and tic regimens for cancer patients, directed at inhibiting definitive antimicrobial therapy for children with cancer and tumor replication, are toxic to all elements in bone marrow, including immunologically competent white suspected infection comes from our experiences in managing blood cells. In addition, patients with a variety of children with primary immunodeficiency. For this reason, the diseases are kept alive for longer periods of time present review examines aspects of management of all using extraordinary supportive measures that offer a patients with primary or acquired immunodeficiency. Consis- much greater chance for eventual colonization with tent infections in all of these patients include bacteremia in multiresistant or unusual microorganisms as well as those with CVLs, Pneumocystis jirovecii pneumonia, primary eventual overt infectious disease. The infectious and reactivation infection with herpes group viruses, and agents that cause such infections are often opportu- opportunistic fungi. nistic organisms. For each medical intervention in Some infections in well-defined groups of immunosuppressed these fragile patients, the physician must calculate hosts are frequent enough to warrant prophylactic therapy; in risk-benefit factors and anticipate adverse events.3 most cases, the duration of such therapy is well defined. Some common complications involve local factors Excessive continuation is likely to lead to colonization and related to diagnostic or therapeutic procedures and to infection with antibiotic-resistant organisms. When antimicro- the placement of indwelling catheters, cannulae, or other foreign bodies. Such factors set the stage for colonization with opportunistic pathogens, which may Address correspondence to then account for significant morbidity and mortality. Russell W. Steele, MD Most patients with diseases that result in second- Ochsner Children’s Health Center ary immunodeficiency receive blood or blood prod- 1315 Jefferson Hwy. ucts during the course of their therapy. The New Orleans, LA 70121 transmission of infectious diseases to these patients Tel: (504) 842-5153 represents a significant risk, particularly for patients Fax: (504) 842-5647 who receive multiple transfusions (Table 2).4 Potential Email: [email protected] blood donors are not screened for many of these Keywords: Bacteremia, cancer, fever, immunodeficiency, infection, agents. Hepatitis is the best-understood and most neutropenia carefully monitored disease, whereas recent litera- ture5 incriminates cytomegalovirus as an agent that is The author has no financial or proprietary interest in the subject increasingly likely to cause severe illness. Blood matter of this article. donors are often asymptomatic for infectious agents 202 The Ochsner Journal Steele, RW Table 1. Iatrogenic Predisposition to Infection Table 3. Primary Immunodeficiency Syndromes in Order of Frequency Local factors; mucosal and skin lesions Drugs (eg, cyclophosphamide) Usual Age Procedures (intravenous administration, cutdown, bone at Diagnosis Gender marrow biopsy) Transient 6-12 months Both Surgical wounds hypogammaglobulinemia Urinary catheters of infancy Intravascular devices (intravenous, intraarterial, central venous Selective immunoglobulin A 4-16 years Both pressure, Swan-Ganz catheters, etc) deficiency Respiratory support (ventilator, intermittent positive pressure Common variable All ages Both breathing, etc) hypogammaglobulinemia Transfusion-transmitted disease Chronic mucocutaneous 1-2 years Both Splenectomy candidiasis Hospital-acquired resistant bacteria (caused by inadequate Cyclic neutropenia All ages Both handwashing) X-linked 6-12 months Male hypogammaglobulinemia (Bruton type) Ataxia telangiectasia 3-5 years Both at the time of phlebotomy. When the recipient of Chronic granulomatous 2 years Primarily male blood products is immunocompromised, additional disease care should be taken in screening donors and Severe combined 9 months Both providing follow-up medical examination of donors immunodeficiency as a routine aspect of the recipient’s care. Additional Wiskott-Aldrich syndrome 1-2 years Male problems of transfusion therapy are pulmonary Thymic hypoplasia 3 months Both edema from volume overload, hemolytic reactions, (DiGeorge syndrome) and other incompletely understood febrile reactions. Complement deficiencies All ages Both Table 2. Infections Transmitted by Blood Transfusions PRIMARY IMMUNODEFICIENCY Bacterial Determining the incidence of primary immunode- Bacterial sepsis ficiency syndromes is difficult because many of the Endotoxemia more severe forms may result in early infant death Brucellosis before a diagnosis. One British study estimated that 1 Syphilis in 50 child deaths was a result of immune dysfunc- 6 Salmonellosis tion. Realistically, primary care physicians only Viral occasionally encounter the more severe defects. Cytomegalovirus More common deficiencies, such as transient hypo- Epstein-Barr virus gammaglobulinemia of infancy and selective immu- Hepatitis A, B, and C viruses (now rare) noglobulin A (IgA) deficiency, are familiar to clinicians. Measles virus Most primary immunodeficiency syndromes pre- Rubella virus sent during infancy or early childhood, with the most Colorado tick fever virus notable exceptions being common variable hypo- Human immunodeficiency virus (now rare) gammaglobulinemia, cyclic neutropenia, and com- Other plement deficiencies that may not become clinically Toxoplasmosis apparent until later in life. The deficiencies of the latter Babesiosis components of complement components 5-8 are not Malaria seen until adolescence or early adulthood with the Leptospirosis presentation of recurrent meningococcal and gono- Filariasis coccal disease. Immunodeficiency syndromes and Trypanosomiasis their usual age at diagnosis are summarized in Table Chagas disease 3. Creutzfeldt-Jakob variant (not established) The approach to therapy varies according to the specific defects demonstrated (Table 4). The most Volume 12, Number 3, Fall 2012 203 Managing Infection in Immunocompromised Children Table 4. Therapeutic Approaches to Immunodeficiency Table 5. Most Common Causes of Secondary Syndromes Immunodeficiency in Children Syndrome Therapy Acquired Splenectomy T cell deficiency immunodeficiency Poor nutrition DiGeorge syndrome Bone marrow transplantation syndrome Other malignancies (thymic aplasia) Sickle cell disease Autoimmune disease Nezelof syndrome Antimicrobial therapy, bone Leukemia Immunosuppressive chemotherapy (thymic hypoplasia) marrow transplantation Nephrotic syndrome Wiskott-Aldrich syndrome Bone marrow transplantation Down syndrome Ataxia telangiectasia Fresh plasma, antibiotics Chronic mucocutaneous Ketoconazole, fluconazole candidiasis suppressive therapy occasionally require Ig supplementation until approx- B cell deficiency imately 18 months of age. Hypogammaglobulinemia Intravenous immunoglobulin replacement Defects in neutrophil function must be followed Selective immunoglobulin Antibiotics closely and treated with antibiotics, especially during Adeficiency acute infectious episodes. Thus, close communica- Complement deficiencies Antibiotics, fresh plasma, tion between patient or parent and physician be- meningococcal vaccine comes the most important aspect of management. T and B cell deficiency Severe combined Bone marrow transplantation SECONDARY IMMUNODEFICIENCY immunodeficiency The suppression of immunologic function with Phagocytosis resulting increased susceptibility to infection may Hyperimmunoglobulin E, Antibiotics result from a number of primary diseases (Table 5). Job syndrome This circumstance is more common in adults than in Chronic granulomatous Antibiotics, interferon, bone children because of the higher incidence of malig- disease marrow transplantation nancy and the greater use of immunosuppressive Neutropenia Antibiotics, granulocyte colony
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