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Transcript
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.