Prevention of infections in hematopoietic cell transplant recipients
- John R Wingard, MD
John R Wingard, MD
- Professor of Medicine
- University of Florida College of Medicine
Allogeneic hematopoietic cell transplant (HCT) recipients are at increased risk for a variety of infections based upon their degree of immunosuppression and exposures. Autologous HCT recipients are also at increased risk for infection, although to a lesser degree than those who have undergone allogeneic HCT.
The term "hematopoietic cell transplantation" will be used throughout this topic review as a general term to cover transplantation of progenitor cells from any source (eg, bone marrow, peripheral blood, umbilical cord blood). (See "Sources of hematopoietic stem cells".)
Patients can develop a range of bacterial, fungal, viral, and/or parasitic infections following HCT. Infection in HCT recipients is associated with high morbidity and mortality. Thus, prevention of infection is a major goal, which involves determination of risk, careful selection of donors, prophylactic and/or preemptive antimicrobial therapy, immunization, and additional measures (eg, infection control).
The prevention of certain infections in HCT recipients will be discussed here; prophylaxis of bacterial infections, invasive fungal infections, and viral infections are discussed in greater detail separately. The evaluation for infection before HCT and an overview of infections following HCT are also presented separately. (See "Prophylaxis of infection during chemotherapy-induced neutropenia in high-risk adults" and "Prophylaxis of invasive fungal infections in adult hematopoietic cell transplant recipients" and "Prevention of viral infections in hematopoietic cell transplant recipients" and "Evaluation for infection before hematopoietic cell transplantation" and "Overview of infections following hematopoietic cell transplantation".)
In 2009, guidelines for preventing infectious complications after HCT were published, which represent the collaboration of several organizations from Europe and North America, including the European Blood and Marrow Transplant Group, the American Society of Blood and Marrow Transplantation, the Canadian Blood and Marrow Transplant Group, the Infectious Diseases Society of America, and the United States Centers for Disease Control and Prevention . Our recommendations are generally in keeping with these guidelines.
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- EVALUATION BEFORE HCT
- TIMELINE FOR INFECTIONS
- IDENTIFYING HIGH-RISK PATIENTS
- GENERAL STRATEGIES TO REDUCE RISK
- Donor selection
- Pre-HCT testing
- Conditioning regimen and dose of hematopoietic cells
- Avoidance of excessive immunosuppression and myelosuppression
- ANTIMICROBIAL PROPHYLAXIS OR PREEMPTIVE THERAPY
- Timing of antimicrobial prophylaxis
- Antibacterial prophylaxis
- - Before engraftment
- - After engraftment
- Antifungal prophylaxis
- Pneumocystis prophylaxis
- Toxoplasma gondii prophylaxis
- Tuberculosis prophylaxis
- Strongyloides prophylaxis
- Antiviral prophylaxis or preemptive therapy
- ADDITIONAL MEASURES
- Infection control measures
- Chlorhexidine bathing
- Blood products
- - Colony stimulating factors
- Intravenous immune globulin
- - Active immunization
- - Passive immunization
- SUMMARY AND RECOMMENDATIONS