Infections in Haematological Malignancies

Question 1

What types of infection do each immune cells combat?

Answer 1

• neutrophils
• bacterial
• fungal
• monocytes
• fungal
• eosinophils
• parasites
• T-lymphocytes
• fungal
• viral
• PJP

Question 2

How is the risk of infection in haematological malignancy reduced?

Answer 2

• prophylaxis
• antibiotics (ciprofloxacin)
• anti-fungal (fluconazole)
• anti-viral (aciclover)
• PJP (co-trimoxazole)
• growth factors
• e.g. G-CSF
• stem cell rescue/transplant
• protective environment
• e.g. laminar flow rooms
• IV immunoglobulin replacement
• vaccination

Question 3

What features of neutropenia cause increased risk?

Answer 3

• cause of neutropenia
• marrow failure, high risk than, immune destruction
• degree of neutropenia
• < 0.5x10⁹/l (significant risk)
• < 0.2x10⁹/l (high risk)
• duration of neutropenia
• > 7 days (high risk)

Question 4

What are other risk factors for infection?

Answer 4

• disrupted skin/mucosal surface
• Hickman line, venflons
• mucositis
• GVHD
• altered floar/antibiotic resistance
• prophylactic antibiotics
• lymphopenia
• disease process, e.g. lymphoma
• treatment
• stem cell transplantation, GVHD
• monocytopenia
• hairy cell leukaemia
• chemotherapy

Question 5

What are bacterial causes of febrile neutropenia?

Answer 5

• gram +ve bacteria (60-70%)
• staphylococci- MRSA, MSSA, coagulase -ve
• streptococci viridans
• enterococcus faecalis/faecium
• corynebacterium spp
• bacillus spp
• gram -ve bacilli (30-40%)
• escherichia coli
• klebsiella spp ESBL
• pseudomonas aeruginosa
• enterobacter spp
• acinetobacter spp
• citrobacter spp
• stenotrophomonas maltophilia
• patterns may relate to antibiotic prophylaxis, emerging infections, use of lines, etc

Question 6

What are possible sites of infection?

Answer 6

• respiratory tract
• GI (typhlitis)
• dental sepsis
• mouth ulcers
• skin sores
• exit sites of venous catheters
• perianal (avoid PR)

Question 7

What kind of infection is common in immunosuppressed patients?

Answer 7

• fungal
• candida, aspergillus
• life threatening deep seated infection
• lung, liver, sinuses, brain
• monocytopenia + monocyte dysfunction, contribute to risk

Question 8

What is the presentation of neutropenic sepis?

Answer 8

• fever with no localising signs
• > 38.5˚C or 38˚C on 2 seperate readings, 1 hr apart
• rigors
• chest infection/pneumonia
• skin sepsis- cellulitis
• UTI
• septic shock

Question 9

What are investigation for neutropenic fever?

Answer 9

• history + examination
• blood cultures- Hickman line + peripheral
• CXR
• throat swab + other sites of infection
• sputum
• FBC, renal + liver function, coagulation screen

Question 10

What is the management of neutropenic sepsis?

Answer 10

• resusitation- ABC
• broad spectrum IV antibiotics
• tazocin + gentamycin
• vancomycin/teicoplanin, if gram +ve
• IV antifungals- empiric therapy, if no response at 72 hrs
• CT chect/abdominal/pelvis
• modify treatment based on culture results

Question 11

What can cause risk of infection in severely lymphopenic patients?

Answer 11

• stem cell transplant recipients, esp allogeneic
• recipients of Total Body Irradiation (TBI)
• graft vs host diease
• nucleoside analogues (fludarabine) or ATG
• lymphoid malignancy

Question 12

What are different types of infection in severly lymphopenic patients?

Answer 12

• atypical pneumonia
• pneumocystis jirovecii (PJP)
• CMV
• RSV
• viral
• shingles (varicella zoster)
• mouth ulcers (herpes simplex)
• adenovirus
• EBV (PTLD)
• fungal
• candida
• aspergillus
• mucormycosis
• atypical mycobacteria
• skin lesions, pulmonary + hepatic involvement