Infectious Disease Flashcards
When is FQ ppx indicated?
ANTICIPATED neutropenia ANC< 100 for > 7 days
give while neutropenic
Notice: patient doesn’t have to be neutropenic if anticipated to be (heme cancer!!!
Can use 3rd gen cephalosporin if can’t take FQ
Who gets primary ppx w/ antifungal agent?
-acute leukemia pts receiving intensive remission INDUCTION therapy
-pre-engraftment phase following HCT
->10% risk candidiasis or >6% risk aspergillus
-give during periods of neutropenia!!! (don’t confuse with secondary ppx where it’s given for duration of tx)
-CONSIDER IF: Profound/prolonged neutropenia- ANC<100 for >7day
Antifungal primary ppx- AML/MDS
Posaconazole (category 1)
Alternate: voriconazole
These are mold active
Caution with IV forms of these if crcl<30 d/t cyclodextrin
Antifungal primary ppx- ALL
Fluconazole, echinocandin, or ampho B
Who gets secondary anti-fungal ppx?
IDSA: prior IFI and expected neutropenia duration 14+ days
NCCN: during subsequent chemo cycles or HCT in pts with prior IFI
Antifunal ppx is given for duration of immunosuppression even if neutropenia resolves (this is different than primary ppx which is given during periods of neutropenia
Who gets HSV ppx? Which drugs are used?
-pts undergoing acute leukemia induction
-CLL (if purine analog, bendamustine, or alemtuzumab, PIK3CA-inhibitors)
-alemtuzumab-regardless of CD4 count
-polatuzumab
-give during active therapy
-CD38 mAb
-consider for purine analog therapy
-consider for other hematologic malignancies
-hairy cell leukemia (x3 months after therapy and CD4 200+)
-acyclovir, valacyclovir, famciclovir
Who gets VZV ppx? Which drugs are used?
-pts w/ impaired cellular immunity (allogenic HCT)
-consider also for prolonged neutropenia, and t-cell depleting agents (Fludarabine, alemtuzumab- regardless of CD4) or proteosome inhibitors
-give during active therapy
-acyclovir, valacyclovir, famciclovir
Who gets pjp ppx? Which meds are used?
-Notice AML is not listed here
-chemo regimens w/ >3.5% risk
->= 20 mg pred x at least one month, or >30 mg x >3weeks (melanoma)
-purine analog based therapy for >1mo
-ALL throughout anti-leukemic therapy
-alemtuzumab
-PI3K inhibitors
-TMZ + RT
-polatuzumab
-give during active therapy or until CD4 count >200 for alemtuzumab
-CLL: bendamustine based immunotherapy
-hairy cell leukemia (x3 months after therapy and CD4 200+)
*Bactrim, dapsone, aerosolized or IV pentamidine, atovaquone
High risk ABX for cdif
FQ, clindamycin, cephalosporins
Aspergillus treatment
DOC: voriconazole
Alternatives: amphoterecin liposomal(esp if 3a4 interactions ), isavuconazole
Duration: 6-12 weeks or even months-years
don’t use echinocandin upfront
***Use TDM for voriconazole with a goal trough if 2-5 mcg/L
fever, chest pain, hemoptysis
Mold (e.g., aspergillus) ppx
Posaconazole (voriconazole is an alternative- don’t confuse with Tx of aspergillus where vori is preferred)
Use in AML/MDS induction
Triazole drug interactions (3A4)
Fluconazole and isavuconazole less severe
-vinca alkaloids
-irinotecan
-HD-cyclophosphamide
-thiotepa
-PO small molecules (e.g., dasatinib, venetoclax, midostaurin)
Separation of vaccines from chemo
-Live: give at least 4 wks before chemo (risk of infxn)
-Inactivated: give at least 2 weeks before chemo (vaccine won’t work- will need to repeat)
if can’t do before, give vaccine 3 months after chemotherapy
or 6 months after anti B-cell therapy
-Covid vaccine:
-solid tumor- vaccinate when available
-heme CA- hold until ANC recovers
-HCT or CAR-T- revaccinate 3 months after
Flu:
-anti-B cell antibodies: 6 mo after
-CAR-T/BiTE (blinatumomab)1 yr after
Flu vaccine
-give normal age appropriate
-these people should not get it:
-b cell antibodies within 6 months
-intensive chemo induction (acute leukemia)
-blinatumomab
-CAR-T
Pneumococcal
-PCV15 or PCV20 for newly diagnosed
-PPSV23 at least 8 weeks after PCV15 (but not after PCV20)
-if previous PPSV23- give either PCV15 or PCV20 at least 1 yr later
Herpes Zoster
RZV (shingrix) for immunocompromised adults >19y- 2 doses separated by 2-6 months
Vaccines for household members
-no live flu vaccine
-some other live are ok (MMR) while others are not (polio)
Vaccine during ICI therapy
No live for 1 month before or 3 months after
Covid vaccines
-Prefer mRNA (Pfizer/Moderna for primary series
-3 dose series for: tx of hematologic ca, organ transplant, CAR-T, HIV, steroids
-no need to delay following antibodies
->3 months after HCT/CAR-T
-no need to delay after mabs
-if heme-chemo wait til ANC recovers
-separate from surgery by a few days
-for solid tumor chemo just vaccinate when vaccine available
-4 wks before or 6 months after B cell therapy
-2 wks before immunosuppressive therapies
-don’t give Evusheld for at least 2 weeks after
Low v high risk FN
Low: MASCC >/=21, CISNE<3, talcotts group 4
High: MASCC<21, CISNE >/=3, talcotts 1-3
-assess MASCC and Talcotts first- if low risk proceed to CISNE to confirm only if pt has a solid tumor and had chemo recently
Proteosome inhibitor: ppx
VZV ppx
BTK inhibitors: Ppx
Acalabrutinib, ibrutinib, zanubrutinib
Consider pjp and VZV if additional risk factors
