Chapter 082. Infections in Patients with Cancer (Part 2)

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A similar problem can affect patients whose lymph node integrity has been disrupted by radical surgery, particularly patients who have had radical node dissections. A common clinical problem following radical mastectomy is the development of cellulitis (usually caused by streptococci or staphylococci) because of lymphedema and/or inadequate lymph drainage. In most cases, this problem can be addressed by local measures designed to prevent fluid accumulation and breaks in the skin, but antibiotic prophylaxis has been necessary in refractory cases. A life-threatening problem common to many cancer patients is the loss of the reticuloendothelial capacity to clear microorganisms after splenectomy. ...

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Chapter 082. Infections in Patients with Cancer (Part 2) A similar problem can affect patients whose lymph node integrity has been disrupted by radical surgery, particularly patients who have had radical node dissections. A common clinical problem following radical mastectomy is the development of cellulitis (usually caused by streptococci or staphylococci) because of lymphedema and/or inadequate lymph drainage. In most cases, this problem can be addressed by local measures designed to prevent fluid accumulation and breaks in the skin, but antibiotic prophylaxis has been necessary in refractory cases. A life-threatening problem common to many cancer patients is the loss of the reticuloendothelial capacity to clear microorganisms after splenectomy.
Splenectomy may be performed as part of the management of hairy cell leukemia, chronic lymphocytic leukemia (CLL), and chronic myelocytic leukemia (CML) and in Hodgkin's disease. Even after curative therapy for the underlying disease, the lack of a spleen predisposes such patients to rapidly fatal infections. The loss of the spleen through trauma similarly predisposes the normal host to overwhelming infection for life after splenectomy. The splenectomized patient should be counseled about the risks of infection with certain organisms, such as the protozoan Babesia (Chap. 204) and Capnocytophaga canimorsus (formerly dysgonic fermenter 2, or DF-2), a bacterium carried in the mouths of animals (Chaps. 140 and e14). Since encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis) are the organisms most commonly associated with postsplenectomy sepsis, splenectomized persons should be vaccinated (and revaccinated; Table 82-2 and Chap. 116) against the capsular polysaccharides of these organisms. Many clinicians recommend giving splenectomized patients a small supply of antibiotics effective against S. pneumoniae, N. meningitidis, and H. influenzae to avert rapid, overwhelming sepsis in the event that they cannot present for medical attention immediately after the onset of fever or other symptoms of bacterial infection. A few amoxicillin/clavulanic acid tablets are a reasonable choice for this purpose. Table 82-2 Vaccination of Cancer Patients Receiving Chemotherapy
Use in Indicated Patients Vaccine Intensive Hodgkin's Hematopo Chemotherapy Disease ietic Stem Cell Transplantation Diphtheria- Primary No special 12, 14, and tetanusa series and boosters recommendation 24 months after as necessary transplantation Poliomyelitisb Complete No special 12, 14, and primary series and recommendation 24 months after boosters transplantation Haemophilus Primary Immunizati 12, 14, and influenzae type b series and booster on before 24 months after conjugate for children treatment and transplantation booster 3 months afterward
Hepatitis A Not Not Not routinely routinely routinely recommended recommended recommended Hepatitis B Complete No special 12, 14, and series recommendation 24 months after transplantation 23-Valent Every 5 Immunizati 12 and 24 pneumococcal years on before months after polysaccharidec treatment and transplantation booster 3 months afterward 4-Valent Should be Should be Should be meningococcal administered to administered to administered to conjugated splenectomized splenectomized splenectomized patients and patients and patients and patients living in patients living in patients living in endemic areas, endemic areas, endemic areas, including college including college including college
students in students in students in dormitories dormitories dormitories Influenza Seasonal Seasonal Seasonal immunization immunization immunization Measles/mumps/r Contraindic Contraindi After 24 ubella ated cated during months in patients chemotherapy without graft- versus-host disease Varicella-zoster Contraindic Contraindi Contraindi virus atede cated cated a The Td (tetanus-diphtheria) combination is currently recommended for adults. Pertussis vaccines have not been recommended for people >6 years of age in the past. However, recent data indicate that the Tdap (tetanus–diphtheria– acellular pertussis) product is both safe and efficacious in adults. b Live-virus vaccine is contraindicated; inactivated vaccine should be used.
c The seven-serotype pneumococcal conjugate vaccine is currently recommended only for children. It is anticipated that future vaccines will include more serotypes and will be recommended for adults. d Currently licensed for people 11–55 years of age. e Contact the manufacturer for more information on use in children with acute lymphocytic leukemia.