This document discusses infections in immune-compromised hosts, including:
1) General principles of infections in this population, including potential etiologies, importance of early diagnosis, and challenges of treatment.
2) Specific sections covering infections in hematopoietic bone marrow transplant recipients, solid organ transplant recipients, HIV/AIDS patients, chemotherapy-induced neutropenic patients, and those receiving immunosuppressive therapy.
3) Guidelines for evaluation, diagnosis, and management of infections in these high-risk groups. Prevention through prophylactic antibiotics, antivirals and antifungals is a major focus.
Viral hepatitis is the leading cause of liver cancer and the most common reason for liver transplantation
In the United States, an estimated 1.2 million Americans are living with chronic Hepatitis B and 3.2 are living with chronic Hepatitis C
Many do not know they are infected
Each year an estimated 21,000 persons become infected with Hepatitis A; 35,000 with Hepatitis B, and 17,000 with Hepatitis C
Hepatitis A – fecal/oral, contaminated food, vaccine available
Hepatitis B – blood, semen, vertical (mother-child), vaccine available
Hepatitis C – blood (IV drug use, transfusion, organ donation, unsterile injecting equipment, sexual intercourse)
Hepatitis D – survives only in cells co-infected with hepatitis B
Hepatitis E* – contaminated food or water, fecal/oral
*causes short-term disease and is not a chronic carrier state
Tuberculosis (TB) is an infectious disease usually caused by Mycobacterium tuberculosis (MTB) bacteria. Tuberculosis generally affects the lungs, but can also affect other parts of the body. Most infections show no symptoms, in which case it is known as latent tuberculosis.
TB is spread from person to person through the air. When people with lung TB cough, sneeze or spit, they propel the TB germs into the air. A person needs to inhale only a few of these germs to become infected.
This is a PowerPoint on the Marburg virus, which is a disease similar to Ebola. I very briefly talk about what the disease is, some of the key facts about the structure and death rate, some outbreak history, prevention and treatment and the social-economical impacts that have been caused.
At the end of the session, the students shall be able to
Describe the HIV AIDS introduction, epidemiology of HIV AIDS, diagnosis of HIV AIDS, treatment of HIV AIDS and prevention control of HIV AIDS.
HIV (Human Immunodeficiency Virus) infects cells of the immune system and destroys or impairs their function.
Infection progressive deterioration of the immune system breaking down the body's ability to fight out infections & diseases by opportunistic bacteria, viruses and fungi.
AIDS (Acquired Immune Deficiency Syndrome) refers to the most advanced stages of HIV infection and a collection of signs and symptoms caused by more than 20 opportunistic infections or related cancers.
Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV).
Viral hepatitis is the leading cause of liver cancer and the most common reason for liver transplantation
In the United States, an estimated 1.2 million Americans are living with chronic Hepatitis B and 3.2 are living with chronic Hepatitis C
Many do not know they are infected
Each year an estimated 21,000 persons become infected with Hepatitis A; 35,000 with Hepatitis B, and 17,000 with Hepatitis C
Hepatitis A – fecal/oral, contaminated food, vaccine available
Hepatitis B – blood, semen, vertical (mother-child), vaccine available
Hepatitis C – blood (IV drug use, transfusion, organ donation, unsterile injecting equipment, sexual intercourse)
Hepatitis D – survives only in cells co-infected with hepatitis B
Hepatitis E* – contaminated food or water, fecal/oral
*causes short-term disease and is not a chronic carrier state
Tuberculosis (TB) is an infectious disease usually caused by Mycobacterium tuberculosis (MTB) bacteria. Tuberculosis generally affects the lungs, but can also affect other parts of the body. Most infections show no symptoms, in which case it is known as latent tuberculosis.
TB is spread from person to person through the air. When people with lung TB cough, sneeze or spit, they propel the TB germs into the air. A person needs to inhale only a few of these germs to become infected.
This is a PowerPoint on the Marburg virus, which is a disease similar to Ebola. I very briefly talk about what the disease is, some of the key facts about the structure and death rate, some outbreak history, prevention and treatment and the social-economical impacts that have been caused.
At the end of the session, the students shall be able to
Describe the HIV AIDS introduction, epidemiology of HIV AIDS, diagnosis of HIV AIDS, treatment of HIV AIDS and prevention control of HIV AIDS.
HIV (Human Immunodeficiency Virus) infects cells of the immune system and destroys or impairs their function.
Infection progressive deterioration of the immune system breaking down the body's ability to fight out infections & diseases by opportunistic bacteria, viruses and fungi.
AIDS (Acquired Immune Deficiency Syndrome) refers to the most advanced stages of HIV infection and a collection of signs and symptoms caused by more than 20 opportunistic infections or related cancers.
Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV).
AIDS stands for: Acquired Immune Deficiency Syndrome
AIDS is a medical condition. A person is diagnosed with AIDS when their immune system is too weak to fight off infections.
Since AIDS was first identified in the early 1980s, an unprecedented number of people have been affected by the global AIDS epidemic. Today, there are an estimated 33.3 million people living with HIV and AIDS worldwide.
http://www.pediatricdentists.blogspot.com
Bronchial Thermoplasty (BT) Novel Treatment for Patients with Severe AsthmaBassel Ericsoussi, MD
Do our Asthma Patients Know What They Are Missing?Now, A Revolutionary Procedure Can Help Them Lead A Fuller Life.
Bronchial Thermoplasty (BT) Novel Treatment For Patients With Severe Asthma
HEMODYNAMICS MONITORING IN CRITICALLY ILL PATIENTS: ASSESSMENT OF FLUID STATU...Bassel Ericsoussi, MD
Invasive methods are well accepted, but there is increasing evidence that these methods are neither accurate nor effective in guiding therapy
An accurate and non-invasive measurement of CO is the best method of cardiovascular assessment
Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer St...Bassel Ericsoussi, MD
EBUS-TBNA, EUS-FNA or their combination have finally gained acceptance as the tests of first choice in mediastinal staging. In suspected non-small cell lung cancer, endobronchial ultrasound may be preferred in the histologic sampling of paratracheal and subcarinal mediastinal adenopathy because the diagnostic yield can surpass mediastinoscopy
THE VENTILATOR CIRCUIT AND VENTILATOR-ASSOCIATED PNEUMONIA (VAP) Bassel Ericsoussi, MD
THE VENTILATOR CIRCUIT APPEARS TO HAVE ONLY A SMALL EFFECT ON THE DEVELOPMENT OF VAP. This contradicts the widely held belief that the ventilator circuit is an important contributor to the development of VAP
New technology called Electromagnetic Navigation Bronchoscopy® (ENB) that uses virtual bronchoscopy and real time 3-dimensional CT images that enable me to localize these peripheral lung nodules for diagnosis and treatment. This outpatient procedure is minimally invasive and therefore has a small risk of pneumothorax (2-3%) and its published diagnostic yield rates range from 67% - 86%
The Role Of Corticosteroids In The Perioperative Management Of Endobronchial ...Bassel Ericsoussi, MD
FBs, particularly those with high oil content may cause severe mucosal inflammation with formation of bulky granulation tissue. When a FB is completely encased in bulky and bleeding granulation tissue, extraction can be very difficult or impossible. A short course of corticosteroids may reduce the inflammatory process and enhance recovery pre or post extraction and in some cases may facilitate removal of the FB.
Whole-lung lavage is a large-volume BAL that is performed mainly in the treatment of PAP. In brief, it involves the induction of general anesthesia followed by isolation of the two lungs with a double-lumen endotracheal tube and performance of single-lung ventilation while large volume lavages are performed on the nonventilated lung. Warmed normal saline solution in 1-L aliquots (total volumes up to 20 L) is instilled into the lung, chest physiotherapy is performed, then the proteinaceous effluent is drained with the aid of postural positioning. The sequence of events is repeated until such time as the effluent, which is initially milky and opaque, becomes clear. This procedure results in significant clinical and radiographic improvement secondary to the washing out of the proteinaceous material from the alveoli. The whole-lung lavage video details all aspects of the procedure, including case selection, patient preparation and equipment, a step-by-step review of the procedure, and postoperative considerations.
Dynamic Central Airway Obstruction: Tracheomalacia, Tracheobronchomalacia, An...Bassel Ericsoussi, MD
Dynamic Central Airway Obstruction: Tracheomalacia, Tracheobronchomalacia, And Excessive Dynamic Airway Collapse: Classification, Diagnosis, and Treatment
Deep Venous Thrombosis and Pulmonary Embolism : Diagnostic Approach and Curre...Bassel Ericsoussi, MD
Acute pulmonary embolism: Overview, Diagnosis, Treatment
DVT/PE in pregnancy
Prevalence of PE in COPD exacerbations
Diagnostic vascular ultrasonography
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Infections In Immunecompromised Hosts Pocket ICU Medicine
1. INFECTIONS IN THE IMMUNE-COMPROMISED HOSTS
Pocket ICU Management
M. Bassel Ericsoussi, MD
Resident, Internal Medicine
University of Illinois at Chicago
Advocate Christ Medical Center
Joehar Hamdan, MD
Resident, Internal Medicine
University of Illinois at Chicago
Advocate Christ Medical Center
Sherif Afifi, MD, FCCM, FCCP
Associate Professor
Anesthesiology and Surgery
Northwestern University Feinberg School of Medicine
Chicago, IL
Contact Information:
Sherif Afifi, MD
251 East Huron St.,
Feinberg 8 – 336A
Chicago, IL 60611-2908
Tel: 312-926-2537
Fax:312-926-4949
s-afifi@northwestern.edu
2. INFECTIONS IN THE IMMUNE-COMPROMISED HOSTS
DEFINITION
• A state in which the response of the host to a foreign antigen is sub-normal.
GENERAL PRINCIPLES
Potential etiologies:
•
Common, community-acquired bacterial and viral diseases.
•
Uncommon opportunistic infections.
•
Multiple simultaneous processes are common.
•
Early imaging (CT scan) and tissue-based diagnosis (histopathology and cultures) are critical to
•
survival of the immunocompromised patient with pneumonia.
Microbicidal therapy must be started as soon as possible.
•
Inflammatory responses are impaired by immunosuppressive therapy, which results in diminished
•
symptoms and muted clinical and radiologic findings.
Infections are often advanced (ie, disseminated) at the time of clinical presentation.
•
The choice of antimicrobial regimens is often more complex.
•
Antimicrobial resistance is increased.
•
Surgical intervention is often necessary.
•
INITIAL EVALUATION
Rapid assessment of vital signs including oxygen saturation.
•
Complete blood count with differential.
•
Electrolytes, blood urea nitrogen and creatinine.
•
Blood cultures (minimum of two with at least one peripheral and one from any indwelling catheter).
•
Urine sediment examination and culture.
•
Sputum for Gram's stain, fungal smears, and cultures.
•
Imaging of the lungs (chest radiography or whenever possible, chest computed tomographic [CT]
•
scanning) and imaging of any symptomatic site (eg, abdomen)
Perineal exam to exclude perirectal infection.
•
DIAGNOSTIC APPROACHES
Serologic testing is not generally useful since seroconversion is often delayed.
•
Antigen-based tests (ELISA, PCR) are needed in this population.
•
3. Diagnosis often requires imaging studies (CT, MRI) due to the altered anatomy following transplant
•
surgery.
Expectorated sputum should be sent for Gram stain examination, acid-fast bacilli smear, and
•
bacterial and mycobacterial culture.
If transbronchial biopsy is contraindicated, BAL alone continues to have a good overall diagnostic
•
yield.
Fiberoptic bronchoscopy (FOB) remains the procedure of choice for diagnosing many pulmonary
•
diseases.
Tissue biopsies are often needed.
•
INFECTIONS IN THE IMMUNO-COMPROMISED HOSTS
Infections in the hematopoietic bone transplant recipient.
•
Infections in the solid organ transplant recipient.
•
Infections in the HIV/AIDS patient.
•
Infections in the chemotherapy-induced neutropenic fever.
•
Infections in patient receiving immunesuppressive therapy.
•
INFECTIONS IN THE HEMATOPOIETIC BONE TRANSPLANT RECIPIENT
Two types of allogeneic vs. autologous:
•
• Allogeneic HCT: at increased risk for a variety of infections based upon their degree of
immunosuppression and exposures.
• Autologous HCT: only vulnerable to infection during the pre and immediate
postengraftment periods.
The types of infections can be roughly divide based upon the time elapsed since transplantation.
•
• Pre-engraftment (less than 3 weeks): The major risk factors are:
• Neutropenia.
• Organ dysfunction.
• Mucositis and cutaneous damage.
• Immediate postengraftment (3 weeks to 3 months): The major risk factors are:
• Mucositis and cutaneous damage.
• Cellular immune dysfunction.
• Immunomodulating viruses.
• Hyposplenism.
• Decrease in opsonization.
• Diminished reticuloendothelial function.
• Acute graft versus host disease (GVHD) and its therapy in allogeneic HCT
recipients.
• Late post-engraftment (after 3 months): The major risk factor is chronic GVHD and its
therapy
4. INFECTIONS IN THE SOLID ORGAN TRANSPLANT RECIPIENT
The types of infections can be roughly divide based upon the time elapsed since transplantation.
•
Less than 1 month:
•
• Infection with antimicrobial resistant species: MRSA, VRE, Candida Species (non-
albicans)
• Aspiration
• Catheter Infection
• Wound Infection
• Anastomotic leaks and ischemia
• Clostridium difficile colitis
• Donor Derived Infection: HSV, LCMV, rhabdovirus, West Nile Virus, HIV, Trypansoma
Cruzi
• Recipient Derived Infection (colonization): Aspergillus, Pseudomonas
1 to 6 months post transplant:
•
• With PCP and antiviral (CMV and HBV) prophylaxis: Polyomavirus BK infection,
Clostridium difficile colitis, HSV, Adenovirus, Cryptococcus Neoformans, Mycobacterium
Tuberculosis.
• Anastomotic Complications
• Without prophylaxis: Pneumocystis, HSV, VZV, EBV, CMV, HBV, Listeria, Norcardia,
Toxoplasma, Strongyloides, Leishmania, T. Cruzi,
More than 6 months:
•
• Community acquired pneumonia, urinary tract infections, Aspergillus atypical molds, mucor
species, Norcardia, Rhodococcus species.
Late Viral infections: CMV colitis and retinitis, HBV, HCV, HSV encephalitis, West Nile Virus,
•
SARS, JC polyomavirus infection.
INFECTIONS IN THE HIV/AIDS PATIENT
The occurrence of specific infections is closely correlated with the degree of impairment of host
•
defenses
• The CD4 count (or the quot;stagequot; of HIV) can provide information about the type of infection to
which the patient is susceptible:
• Early (CD4 >500 cells/mm3): Bacterial pneumonia, TB and HHV-8 related Kaposi's
sarcoma.
• Intermediate (CD4 200 to 500 cells/mm3).
• Advanced (CD4 100 to 200 cells/mm3): PCP, disseminated fungal disease.
• Late stage disease (CD4 <100 cells/mm3): PCP, disseminated fungal disease
Sinusitis and bronchitis can occur at any CD4 count.
•
Human herpesvirus-8 (HHV-8)-related Kaposi's sarcoma occurs almost exclusively in HIV-infected
•
men who have sex with men (MSM).
The recommended prophylaxis according to CD4 count:
•
• CD4 count <200/mm3 thrush; unexplained fever for more than two weeks; history of PCP:
Pneumocystis carinii pneumonia.
•
• CD4 count <100/mm3 and Toxoplasma sero- positive toxoplasmosis:
• CD4 count <50/mm3 myocabacterium avium complex:
5. CD4 count <150/mm3 and lives in an endemic area histoplasmosis:
•
INFECTIONS IN CHEMOTHERAPY-INDUCED NEUTROPENIC FEVER
Defined as a single temperature of >38.3ºC (101.3ºF), or a sustained temperature >38ºC (100.4ºF)
•
for more than one hour.
Absolute neutrophil count (ANC) <500 cells/microL.
•
Pathogenesis:
•
• Chemotherapy-induced mucositis.
• Deficits related to the underlying malignancy.
Bacterial infections:
•
• More Common: Staphylococcus aureus, staphylococcus epidermidis, streptococci, and
tuberculosis reactivation.
• Less common: Corynebacterium jeikeium, bacillus, propionibacterium acne.
Fungal infections: Candida albicans, aspergillus, fusarium sp., reactivation of endemic fungi
•
(histoplasmosis, blastomycosis, coccidioidomycosis).
Viral infections: HSV-1 and 2 (encephalitis, meningitis, myelitis, esophagitis, pneumonia, hepatitis,
•
erythema multiforme, and ocular disease), herpes zoster, cytomegalovirus, epstein Barr virus,
HHV-6.
INFECTIONS IN PATIENT RECEIVING IMMUNESUPPRESSIVE THERAPY
The spectrum of infections may include common pathogens, opportunistic infections, and
•
sometimes normal flora.
The degree of immune deficiency is dependent upon the condition being treated, the doses of
•
single agents, and drug combinations that are frequently synergistic.
Laboratory studies of immune function are often used to monitor therapy.
•
Mechanisms:
•
• Alteration in macrophage function.
• The induction of suppressor T cells.
• Depression of cell-mediated.
• Production of immunosuppressive factors.
Microbial infections:
•
• Measles: pneumonia, gastroenteritis, otitis media, gingivostomatitis, and
laryngotracheobronchitis.
• Herpesviruses:
• Bacterial infections
• Micobacterial infections
• Parasite infestation: Malaria infection
GENERAL MANAGEMENT PRINCIPLES
The central focus must be on disease prevention by drug therapy and vaccination.
•
Microbicidal therapy must be started as soon as possible.
•
Empiric therapy should be based upon available data. Overly broad antimicrobial therapy can then
•
be modified based upon new microbiologic data.
6. The choice of antimicrobial regimens is often more complex than in other patients.
•
Antimicrobial resistance is increased.
•
Surgical intervention is often necessary to cure localized infections (debridement); antimicrobial
•
agents alone are frequently inadequate.
Reduction of the overall level of immune suppression may be as important as antimicrobial therapy
•
in the ultimate success of treatment.
PREVENTION AND PROPHYLAXIS IN TRANSPLANT PATIENT
1) Antibacterial prophylaxis
Suppress intestinal flora to prevent gram-negative bacterial infections during neutropenia.
•
Levofloxacin (prophylactic agents of choice) reduce the frequency of gram-negative
•
infection and provide excellent coverage against gram-positive infections.
The duration of prophylaxis depends upon the degree of immunosuppression and
•
institutional protocols.
Patients with severe GVHD requiring immunosuppressive drugs remain on both
•
antibacterial and antifungal prophylaxis until the immunosuppressive drugs are no longer
necessary.
Prophylaxis against the pneumococcus (penicillin, trimethoprim-sulfamethoxazole, and
•
newer fluoroquinolones) in all allogeneic transplant recipients
Autologous recipients do not require routine prophylaxis directed at the pneumococcus
•
following engraftment unless they are at additional risk for severe pneumococcal infection
or are receiving ongoing immunosuppresive therapy.
2) Antiviral prophylaxis: Both prophylaxis and preemptive strategies are employed for a variety of
viral infections.
• Herpes simplex virus
• When tolerated, oral acyclovir is equally effective and costs less.
• Continue acyclovir as long as the patient is severely immunosuppressed (CD4
count <200/mm3).
• Acyclovir (use for> 1 year) was associated with optimal suppression of disease
compared to shorter durations of prophylaxis.
• Cytomegalovirus
• Intravenous ganciclovir to prevent reactivation of endogenous CMV in CMV
seropositive recipients or in patients receiving organs from a seropositive.
• High-dose acyclovir may also be effective.
• Many centers favor a preemptive approach (screening for CMV following
transplantation and treating only those shedding antigen) rather than prophylaxis
to minimize toxicity.
Varicella zoster virus
•
• Varicella zoster virus (VZV) can cause severe disease in transplant patients.
• VZV prophylaxis with acyclovir for one year following transplantation and longer
prophylaxis to patients requiring ongoing immunosuppression.
Epstein-Barr virus
•
7. • Epstein-Barr virus (EBV) reactivation may progress to life-threatening EBV-related
posttransplantation lymphoproliferative disorder (PTLD): uncontrolled proliferation
of B cells.
• PCR is an important tool for monitoring EBV reactivation.
• CD20 monoclonal antibodies (rituximab) is effective in rapidly reducing levels of
proliferating B cells.
• Acyclovir and ganciclovir are unable to limit B cell proliferation in PTLD
3) Antifungal prophylaxis
• Fungal infections are a frequent cause of transplant-related mortality (Candida and
Aspergillus species).
• Fluconazole, itraconazole, posaconazole, and micafungin prevent invasive fungal
infections in transplant recipients without causing significant toxicity.
• Fluconazole prophylaxis is associated with significant reductions in fungal colonization,
systemic fungal infection and mortality.
• Itraconazole is poorly tolerated (hepatotoxicity and gastrointestinal irritation).
• The benefit of prophylactic amphotericin B remains uncertain.
• Prophylaxis for candidiasis
• Colonization with fluconazole-susceptible candida spp: Oral fluconazole starting
the first day of neutropenia and continuing until immunosuppression has resolved.
• Patients colonized with fluconazole-resistant Candida spp (C. glabrata or C.
krusei), an echinocandin, such as caspofungin, micafungin, or anidulafungin,
should be considered.
• Preemptive therapy for aspergillosis
• Screen high-risk patients for markers of colonization and/or infection.
• Nasal culture.
• Aspergillus polymerase chain reaction (PCR).
• Serum Aspergillus galactomannan.
• Serum beta-D-glucan.
• If markers are positive, high-resolution CT scan of chest and a CT scan of sinuses
and/or other potential sites of infection.
• If you suspect invasive aspergillosis, start voricinazole.
• If voriconazole cannot be given, amphotericin B is the preferred alternative.
• Posaconazole and voriconazole can be used for prophylaxis.
4) Antiparasitic prophylaxis
• Pneumocystis jiroveci
• Start after engraftment and continued for as long as immunosuppressive therapy
is given and the CD4 cell count is <200 cells/microL.
• TMP-SMX (the drug of choice)
• TMP-SMX offers protection against various potential pathogens in this
patient population including Streptococcus pneumoniae, Haemophilus
influenzae, enteric bacterial pathogens, and toxoplasmosis.
• Atovaquone, aerosolized pentamidine, and dapsone (if the patient is allergic to
TMP-SMX or there is concern about bone marrow toxicity)
• Toxoplasma gondii
8. • It is often fatal opportunistic infection.
• Since the disease mostly reflects reactivation of latent infection, it is advisable to
determine the toxoplasma serologic status of all patients undergoing
transplantation.
• Chemoprophylaxis for toxoplasmosis (pyrimethamine sulfadoxine, TMP-SMX)
after engraftment may be helpful in seropositive patients in highly endemic areas.
Anti-mycobacterial prophylaxis
•
• Reserved for patients identified as high-risk during the pretransplant evaluation.
• Isoniazid prophylaxis, starting before transplantation and continuing during the
transplant period has been suggested.
PREVENTION AND PROPHYLAXIS IN HIV
Pneumocystis (CD4 count < 200 cells/microL).
•
TMP-SMX as first-line (also in pregnancy 2nd, 3rd trimester).
•
Dapsone (pt who cannot tolerate TMP-SMX).
•
Atovaquone (who cannot tolerate TMP-SMX or dapsone).
•
Aerosolized pentamidine (pregnancy, 1st trimester).
•
Toxoplasma (CD4 count <100 cells/microL and are toxoplasma seropositive).
•
TMP-SMX as first-line (also in pregnancy 2nd, 3rd trimester).
•
Dapsone plus pyrimethamine plus leucovorin (pt who is allergic to TMP-SMX).
•
atovaquone (pt who is intolerant or allergic to the above two regimens).
•
Pyrimethamine is teratogenic and should not be used during pregnancy.
•
Patients who are seronegative for toxoplasma should be counseled to avoid eating
•
undercooked meats and to use gloves when cleaning cat litter boxes.
MAC (CD4 count less than 50 cells/microL).
•
• Blood cultures for MAC isolation should be drawn if there is any suspicion of clinical
disease before starting any prophylactic treatment
• Macrolides (weekly azithromycin rather than daily clarithromycin).
• If azithromycin is not tolerated, clarithromycin should be initiated.
• Rifabutin(If neither macrolide is tolerated), a chest x-ray should be obtained to rule out
active tuberculosis.
• Azithromycin may be used during pregnancy. Clarithromycin is a teratogen in animals and
should not be used during pregnancy.
Histoplasmosis (CD4 count <100 cells/microL and lives in an endemic area)
•
• Itraconazole
Candida
•
• Primary prophylaxis is not recommended
9. Azoles are teratogenic and should not be used during pregnancy.
•
Cryptococcus
•
• Primary prophylaxis is not recommended
• Azoles are teratogenic and should not be used during pregnancy.
Coccidioidomycosis
•
• Primary prophylaxis is not recommended
Cytomegalovirus
•
• Seropositive with CD4 counts <50 cells: Three to six month ophthalmologic examinations
for surveillance of CMV disease AND patient education about the symptoms of CMV
retinitis, including floaters and blurry vision.
• Seronegative, advice should be given about potential routes of transmission; additionally
they should receive CMV antibody negative blood transfusions or leukocyte-reduced
cellular blood products, when needed.
Cryptosporidium
•
• Prophylaxis is not recommended