Immunocompromised traveler Flashcards
What are conditions that are identified as ‘disease without compromise’?
HIV CD4 >500
SOT/BMT >2y
Malignancy chemo>3m and in remission
Corticosteroids <20mg <2w
Autoimmune disease without treatment
MS with no exacerbation and no treatment
What are conditions that are identified as ‘limited compromise’?
HIV CD4 200-500
Complement deficiencies
Asplenia
Chronic renal or liver disease
MS with exacerbation and no treatment
Nutritional deficiencies
What are conditions that are identified as ‘severe compromised’
HIV CD4 <200
BMT/SOT <1y or on immunosuppressants
Active malignancy
CLL
Recent radiation
Aplastic anemia
Congenital immunodeficiency
Corticosteroids >20mg >2w
Thymus disorders
Drugs
Which drugs qualify a patient as ‘severe compromised’
Alkylating agent
Anti-metabolites
Chemotherapy
Immunomodulators
TNF blockers
What are the components of pre-travel consultation?
- Assess traveller’s health
- Assess disease exposure risk
- Administer vaccines
- Administer medical prophylaxis
- Medical care
- Counselling
What history is important for an immunocompromised traveller?
Conditions
Medications
Extremes of age
Immunisation history
Timelines (chemo, transplant)
How do you asses the risk of disease exposure?
- Countries
- Accomodation
- Peak seasons
- Food sources
- Activities
Which conditions can receive medical prophylaxis?
Traveller’s diarrhoea
Malaria
Leptospirosis
Post-splenectomy prophylaxis
What should you counsel a travelling patient on?
- Food and water safety
- Accident prevention
- Insects
- Wear shoes
- Thrombosis prophylaxis
- Altitude sickness
- STIs
- Diving
Which enteric infections can be severe and become chronic in the immunocompromised?
Salmonella
Campylobacter
Cryptosporidium
Are prophylactic quinolones routinely recommended for enteric infections?
No!
But lower threshold for use (and azithromycin in areas with resistance)
What is the risk of traveller’s diarrhoea in patients with impaired renal function?
Dehydration complications
What are specific conditions to consider at risk for malaria?
Asplenia (severe malaria)
HIV (bidirectional interaction)
SOT (can lead to rejection)
Which ARVs interact with antimalarials?
NNRTIs
PIs
Which anti-malarials do NNRTIs interact with?
Mefloquine (specifically efavirenz and NVP)
Which anti-malarials do PIs interact with?
Quinidine
Lumefantrine
Halofantrine
What is the reason for contraindication of PIs with quinidine?
Cumulative cardiac toxicity
Which condition can protect from fatal hemorrhagic dengue fever complication?
Impaired T cell function
Which arbovirus can precipitate SOT rejection?
Dengue
Name encapsulated organisms to consider in asplenic patients
S. pneumonia
N. meningitidis
Haemophilus
Capnocytophaga
What bacterial prophylaxis can you give an asplenic traveller?
Levofloxacin
Moxifloxacin
Augmentin
What is the risk of Babesia infection in asplenic patients?
Highest in 1st 2 years
Children higher risk
Sickle cell at risk
Severe disease
Which travellers are at increased risk of hepatic decompensation follow HAV infection?
HCV
How does TST perform in the immunocompromised?
Decreased sensitivity
