Erin Streu RN MN CON(C) Clinic Nurse, CLL and Lymphoma Clinics
Transcription
Management of Infectious Complications in the CLL Population Erin Streu RN MN CON(C) Clinic Nurse, CLL and Lymphoma Clinics CancerCare Manitoba Disclosure of Potential Conflict of Interest • FINANCIAL DISCLOSURE: None • Other: Employee of CancerCare Manitoba Objectives • Review common infections in the CLL population • Identify ‘at risk’ patients • Review CCMB CLL Clinical Practice Guidelines for the treatment and prevention of infections • Review special considerations when transfusing blood products Common Bacterial Infections Most infections are mucosal in origin affecting: • • Respiratory tract • Skin • Urine Common organisms include: • • S. aureus E. coli • S. pneumoniae H. influenzae Klebsiella pneumoniae Pseudomonas aeruginosa Common Viral Infections • Herpes simplex • • Herpes zoster • • More common in untreated patients 29% incidence Cytomegalovirus (CMV) • Reactivation 10-25% • 50% asymptomatic Opportunistic Infections • Seldom occur in untreated patients • The use of corticosteroids increases the risk • Common organisms include: Listeria • Nocardia • Candida • Aspergillus • Pneumocystis jirovecii • Histoplasmosis • Cryptococcus • Atypical mycobacterium • At-Risk Populations The likelihood of infections increases with: • • the duration of treatment • the number of previous treatments • disease that is not responding to treatment • use of corticosteroids • patients treated with Fludarabine and Alemtuzumab Treatment of Infections • If febrile and on chemotherapy --> HOLD chemotherapy and treat infection • Resume chemotherapy cautiously and ensure prophylaxis is prescribed Preventative Measures 1. Antimicrobial Prophylaxis 2. Immunoglobulin Replacement 3. Vaccines Chemotherapy Prophylaxis Recommendations: Treatment with Fludarabine/Alemtuzumab, history of shingles or cold sores, the elderly, previous infections: • Antibacterial: Cotrimoxazole 960 mg (1 tab) po BID on Saturdays and Sundays OR Dapsone 100mg po 3x/week • Antiviral: Valcyclovir 500mg po od • Antifungal: only if previous fungal infections Duration of treatment and 6 months post CMV Monitoring and Treatment • Check CMV status at baseline and weekly while on ALEMTUZUMAB treatment • >500 copies/mL = threshold for treatment • 2 consecutive weeks positive (or rising) in asx patients OR 1 positive result + fever/sx ---> initiate treatment • Valgancyclovir 900mg po BID until decreasing or low level positive then reduce dosing until 2 consecutive negative results • *As long as afebrile/asymptomatic...Continue Treatment! Hypogammaglobulinemia • Present in up to 86% of patients with CLL • Despite low levels most patients are asymptomatic • Treatment can decrease incidence of bacterial infections by 50% but does not prolong survival • Normal values: 6.9-16.2 g/L Hypogammaglobulinemia Recommendations: IgG <3g/L and recurrent infections requiring antibiotics • • IVIG 400mg/kg Q 3 weeks • Low dose 10 grams Q 3 weeks may be as effective *No evidence that treatment is cost-effective Vaccines CLL patients respond poorly to immunizations and the overall benefit is questionable. Recommendations: • Seasonal influenzae vaccine: Annually • Pneumovax: At Diagnosis • Shingles vaccine: Not Recommended Encourage family members to get vaccinated! Transfusion Considerations • To prevent Graft Versus Host (GVH) Complications • Recommendation: • Anti-CMV and Irradiated Blood Products for Life • Fludarabine • Alemtuzumab • BMT eligible References • CCMB Practice Guideline: Disease Management Consensus Recommendations for the Management of Chronic Lymphocytic Leukemia. (2012). Draft version. • Hamblin, AD. & Hamblin TJ. (2008). The immunodeficiency of chronic lymphocytic leukemia. British Medical Bulletin, 87, 49-62. • Morrison, VA. (2010). Infectious complications of chronic lymphocytic leukemia: pathogenesis, spectrum of infection, prevention approaches. Best Practice & Research Clinical Hematology, 23, 145-153.
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