Infection in patients with Haematological Malignancy

Question 1

Which immune cells do you need?

Answer 1

Neutrophils - bacterial and fungal infection.

Monocytes - fungal infection.
Eosinophils - parasitic infections.
T lymphocytes - fungal and viral infection, PJP.
B lymphocytes - bacterial infection.

Question 2

What are the supportive measures aimed at reducing risk of sepsis?

Answer 2

Prophylaxis 
- antibiotics 
- anti-fungal 
- anti-viral 
PJP 

Growth factors 
Stem cell rescue/transplant
Protective environment 
Intravenous immunoglobulin replacement.
Vaccination.

Question 3

What are additional risk factors for infection?

Answer 3

Disrupted skin / mucosal surfaces.
Altered flora / antibiotic resistance.
Lymphopenia (lymphoma)
Monocytopenia. (chemo)

Question 4

What are the febrile neutropenia bacterial causes?

Answer 4

Gram-positive bacteria (60-70%)

Gram-neagative bacilli (30-40%)

Question 5

What are the gram positive bacteria.

Answer 5

Staphylococci: MSSA, MRSA, coagulase negative. 
Streptococci: viridans
Enterococcus faecalis/faecium 
Corynebacterium spp
Bacillus spp

Question 6

What are the gram negative bacteria?

Answer 6

Escherichia coli 
Klebsiella spp: ESBL 
Pseudomonas aeruginosa. 
Enterobacter spp
Acinetobacter spp 
Citrobacter spp 
Stenotrophomonas maltophilia.

Question 7

What are the possible sites infection?

Answer 7

Respiratory tract 
Gastriointestinal 
Dental sepsis 
Mouth ulcers 
Skin sores 
Exit site of central venous catheters. 
Perianal (avoid PRs)

Question 8

Why are fungal infections so important in immunocompromised patients?

Answer 8

Fungal e.g. Candida species, Aspergillus.
Life threatening deep seated infection.
Lung, liver, sinuses, brain.

Monocytopenia and monocyte dysfunction contributes to risk of fungal infection.

Question 9

How does neutropenic sepsis present?

Answer 9

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

Question 10

What are the sepsis 6?

Answer 10

Administer high flow OXYGEN.
Take BLOOD CULTURES, other cultures. 
Give appropriate IV ANTIBIOTICS with ONE hour. 
Measure serum LACTATE concentration. 
Start IV FLUID RESUSCITATION.
Asses/measure urine output.

Question 11

What does every hour of delay in administering antibiotics ?

Answer 11

Increases chance of mortality by 8%

Question 12

What are the investigation of neutropenic fever?

Answer 12

History and exam.
Blood cultures - Hickman line and peripheral.
CXR
Throat swab and other clinical sites of infection.
Sputum if productive.
FBC, renal and liver function, coagulation screen.

Question 13

What is the management of neutropenic sepsis?

Answer 13

Resuscitation - ABC
Broad spectrum I.V. antibiotics. Tazocin / gentamicin.
If gram positive organsim - vancomycin.
If no response at 72 hours add IV antifungal treatment.
CT chest/abdo/pelvis.
Modify treatment based on culture results.

Question 14

How can infection occur in severely lymphopenic patients?

Answer 14

Stem cell transplant recipients, especially allogeneic.
Recipients of Total Body irradation.
Graft vs Host dieases
Nucleoside analogues
Lymphoid malignancy e.g. lymphoma, CLL,ALL

Question 15

What infections occur in severely lymphopenic patients?

Answer 15

Atypical pneumonia

• pneumocystis Jirovecii
• CMV
• RSV

Viral

• shingles
• mouth ulcers
• Adenovirus
• EBV