Complications After Hematopoietic Stem Cell Transplantation

Published on 04/03/2015 by admin

Filed under Hematology, Oncology and Palliative Medicine

Last modified 04/03/2015

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Chapter 49 Complications After Hematopoietic Stem Cell Transplantation

Table 49-2 Common Infections in Hematopoietic Cell Transplant Recipients

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CMV, Cytomegalovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; HCT, hematopoietic cell transplantation; HLA, human leukocyte antigen; PTLD, posttransplant lymphoproliferative disorder; TMP-SMX, trimethoprim-sulfamethoxazole; wk, week.

* Includes Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis.

Table 49-3 Recommended Antimicrobial Prophylaxis Against Common Infections

Pathogen Preventing Early Disease (0-100 Days After HCT) Preventing Late Disease (>100 Days After HCT)
Bacterial infections No specific recommendations* Antibiotics (based on local resistance patterns) to prevent infections due to encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis) in patients on chronic immunosuppression
Cytomegalovirus Prophylaxis or preemptive treatment with ganciclovir or valganciclovir in high-risk patients Preemptive treatment with ganciclovir or valganciclovir in high-risk patients
Herpes simplex virus Acyclovir in seropositive patients Acyclovir in patients with recurrent HSV infections
Yeast infections Fluconazole Fluconazole in patients on chronic immunosuppression
Mold infections No specific recommendations No specific recommendations*
Pneumocystis jiroveci Trimethoprim-sulfamethoxazole (preferred) or dapsone or pentamidine Trimethoprim-sulfamethoxazole (preferred) or dapsone or pentamidine in patients on chronic immunosuppression

HCT, Hematopoietic cell transplantation; HSV, herpes simplex virus.

*Limited data exist favoring fluoroquinolones such as levofloxacin. No impact on infection-related mortality.

Cytomegalovirus (CMV)-seropositive HCT recipients or CMV-seronegative recipients with a CMV-seropositive donor.

Limited data available. Prospective testing of voriconazole and posaconazole suggests possible benefit as prophylaxis. No impact on mold-related mortality.

Table 49-4 Recommended Vaccinations for Hematopoietic Cell Transplantation Recipients

Vaccine* Time After HCT to Initiate Vaccine No. of Doses
Pneumococcal conjugate 3-6 mo 2-3
DTaP§ 6-12 mo 3
Haemophilus influenzae type b conjugate 6-12 mo 3
Inactivated poliovirus 6-12 mo 3
Recombinant hepatitis B 6-12 mo 3
Inactivated influenza 4-6 mo 1-2 yearly
Measles, mumps, and rubella virus (live) 24 mo 1-2
Varicella-zoster 24 mo 1

DTaP, Diphtheria and tetanus toxoids and acellular pertussis vaccine; HCT, hematopoietic cell transplantation.

*Vaccinations are deferred in patients with chronic graft-versus-host disease (GVHD) until discontinuation of immunosuppression.

A minimum of 1-month interval between doses is suggested.

Following the primary series of three pneumococcal conjugate vaccine (PCV) doses, a dose of the 23-valent pneumococcal polysaccharide vaccine (PPSV23) to broaden the immune response might be given. For patients with chronic GVHD who are likely to respond poorly to PPSV23, a fourth dose of the PCV should be considered instead of PPSV23.

§DTaP is preferred; however, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) can be used if DTaP is not available.

For children younger than 9 years of age, two doses are recommended yearly between transplant and 9 years of age.

Not recommended less than 24 months post-HCT, in patients with active GVHD, and in patients on immune suppression. In children, two doses of measles, mumps, and rubella virus vaccine live are favored. Lower viral-dose vaccines (varicella vaccine live [Varivax], not zoster vaccine live [Zostavax]) may be preferred as potentially safer.