15. Infection In Patients With Haematologicl Malignancy

Question 1

What immune cells do what?

Answer 1

Neutrophils- bacterial and fungal infections
Monocytes- fungal infections
Eosinophils- parasitic infections
T lymphocytes- fungal and viral infection
B lymphocytes- bacterial infection

Question 2

What is an autograft?

What is an allograft

Answer 2

Autograft- stem cell transplant from yourself

Allograft- stem cell transplant from someone else

Question 3

What supportive measure can be used at reducing risk of sepsis in heamatological malignancies?

Answer 3

Prophylaxis- antibiotics (ciprofloxacin), anti-fungal (fluconazole), anti-viral (aciclovir), PJP, (co-trimoxazole)

Growth factors- reduce neutropenic time (e.g. G-CSF)

Stem cell rescue/transplant

Intravenous immunoglobulin replacement

Vaccination (re-vaccination schedule after transplants)

Question 4

What makes you more likely to acquire infections in neutropenia?

Answer 4

Marrow failure (higher risk than immune destruction)
Degree of neutropenia (more severe, more risk of infection)
Duration of neutropenia (>7 days, high risk)
Disrupted skin/mucosal surfaces
Altered flora/antibiotic resistance
Lymphopenia (reduced B+T lymphocytes)
Monocytopenia (indicative of hairy cell leukaemia

Question 5

What gram positive bacteria causes problems in heamatological malignancies?

What antibiotics would you use?

Answer 5

MSSA- flucloxacillin
MRSA- vancomycin
Coagulase negative- penicillin resistant

Strep: viridans
Enterococcus faecalis
Corynebacterium bacillus spp

Question 6

What gram negative bacteria cause problems in heamatological malignancies?

Answer 6

E. Coli

Klebsiella spp (ESBL)- most penicillins wont work

Pseudomonas aeruginosa

Question 7

What are possible sites of infection in heamatological malignancies

Answer 7

Respiratory tract
Gastrointestinal (typhlitis)
Dental sepsis
Mouth ulcers
Skin sores
Exit site of central venous catheters
Perianal (avoid PR’s)

Question 8

What fungal infections cause problems in immunocompromised infections?

Answer 8

Candida species- oral thrush, prone if on steroids or DM

Aspergillus

Question 9

How does neutropenic sepsis arise?

Answer 9

Fever with no localising signs
Single reading of 38.5 or 38 or greater on two readings one hour apart
Rigors?
Chest infection/pneumonia
Skin sepsis- cellulitis
UTI
Septic shock

Question 10

What is the action for neutropenic sepsis?

Answer 10

Still the sepsis six!

Give oxygen
IV antibiotics within one hour
Start IV fluid resuscitations

Take blood culture
Urine output
Serum lactate

Question 11

How can you investigate neutropenic sepsis?

Answer 11

Cultures form line and peripheral blood

CXR

Throat swab and other p sites of infection

Sputum culture if possible

Question 12

How do you manage neutropenic sepsis?

Answer 12

Resuscitation (ABC)

Broad spectrum (tazocin and gent)

If gram + suspected then vancomycin or teicoplanin

If no response after 72 hours add IV antifungal treatment e.g. caspofungin

CT chest/abdo/pelvis

Modify treatment based on culture results

Question 13

What patients are lymphopenic

Answer 13

Stem cell transplant
Recipients of total body radiation
graft vs host disease
nucleoside analogues (fludarabine or ATG)
Lymphoid malignancy e.g. lymphoma, CLL, ALL

Question 14

What sort of infections do lymphopenic patients get?

Answer 14

Pneumocystis jirovecci (PJP)
CMV
RSV

viral
shingles
Mouth ulcers
Adenovirus
EBV (PTLD)

Question 15

Where do fungal infections cause infection?

Answer 15

the lung, liver, sinuses (mucalmicosis) and brain