Page 1639 - Hematology_ Basic Principles and Practice ( PDFDrive )

1460 Part VIII Comprehensive Care of Patients with Hematologic Malignancies

mismatched donors, patients with T cell–depleted transplants, and (S. pneumoniae, H. influenzae type b, Neisseria meningitidis).
patients receiving intensive immunosuppression (e.g., antithymocyte Penicillin-resistant pneumococcal infection has been reported,
globulin). Posttransplant lymphoproliferative disorder after allogeneic prompting consideration of alternate prophylaxis, such as a change
stem cell transplantation most often is of donor origin. Quantitative from penicillins to quinolones. Prophylaxis is generally discontinued
EBV viral load diagnostic testing is relatively new and not standard- 2 years after HSCT, or later if GVHD and immunosuppression are
ized, so the algorithms for monitoring and initiation of treatment ongoing at the 2-year time point. Once the patient is ready for vac-
vary. Recognition of greater than 1000 viral copies/mL of blood cinations, conjugate pneumococcal, meningococcal, and H. influenzae
requires investigation, repeated testing, and possibly treatment, type b vaccines are given.
especially in high-risk patients. Direct antiviral agents have limited
impact on reducing detectable EBV viral loads. General treatment
approaches involve reduction of immunosuppression and rituximab Vaccination
or donor lymphocyte infusion (see Chapter 52).
Recipients of HSCT frequently lose antibody responses to viral and
bacterial pathogens previously targeted by childhood vaccination.
Invasive Mold Infections Although practice varies among transplantation centers, killed-virus
vaccines are often given at 1 year after HSCT and live-virus vaccines
6
Invasive fungal infections are among the most feared complications approximately 2 years after HSCT for patients without GVHD. For
of HSCT both because of their high mortality rates and the difficulty adults, Tdap (formulation of reduced-antigen, combined diphtheria-
4
in establishing a diagnosis. Among HSCT recipients studied at tetanus-acellular pertussis vaccine) has replaced Td (diphtheria-
autopsy, yeast and mold infections were common, seen in more than tetanus booster vaccine) as a means for decreasing the adult reservoir
25% of deaths. The probability of survival is higher in recent years, of pertussis. For protection against hepatitis, the combined vaccine
likely due to newer and more effective agents, as well as nonmyeloab- providing protection against both hepatitis A and B can be used. The
lative conditioning. Posaconazole has been shown to be effective in efficacy of vaccination is influenced by the time elapsed since trans-
5
preventing invasive fungal infections during GVHD. Mold spores plantation, the nature of the hematopoietic graft, the presence of
may initiate a localized infection in the lungs or sinuses that, after GVHD, and the use of serial immunization. Guidelines have been
intensive immunosuppression for GVHD, may disseminate to the published (Chapter 110, Table 110.4).
skin, abdominal organs, or central nervous system. Treatment of
central nervous system infections should include voriconazole, which
attains cerebrospinal fluid levels approximately 50% those of plasma REFERENCES
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