Lymphoid System

- Patients w/ antibody deficiency are predisposed to overwhelming infection w/ encapsulated

bacteria(see table under Humoral immunity)
- Patients undergoing CHEMOTHERAPY for any kind of cancer will have defects due to: 1)
Granulocytopenia; 2) Lymphocyte disfunction
- Glucocorticoids/T cell inh.(Calceneurin inh; Fludarabin)/Cytokine induction inhibitors:
Should be given prophylaxis for Pneumocystis pneumonia
- B Cell inh. (Rifuximab): vulnerable to interviral infection and has Increased Incidence of
Progressive Multifocal Leukoencephalopathy(JC virus)

Hematopoietic System
- Aerobic pathogens predominate
- Anaerobic uncommon
- Like immunocompromised Px, Neutropenic Px are also threatened by their own microbial flora

- Granulocyte count should be

sustained >500uL for atleast 2 days
- Px may remain febrile after resolution
of neutropenia
- DDx Strongly considered:
- Fungal
- Bacterial Abscess/ Undrained
foci of infection
- Drug Fever

Treatment
Antibiotics(see algorithm)
- Agents used should reflect both epidemiology and antibiotic resistance pattern of the hospital
- Most standard regimens are designed for patients who have not previously recieved prophylactic
antibiotics
- Low Risk Px:
- PO antibiotics can be used
- Neutropenic for <10days and w/ no current medical condition
- Febrile Px w/ Prolonged Neutropenia
- Commonly used Regimens
- Ceftazidine or Cefepime
- Piperacillin/Tazobactam
- Imipinem/Cilastatin (Imipinem associated w/ inc. rate of C. difficile diarrhea) or
Meropenem
- Initial antibacterial regimen should be refined on the basis of culture results
- Blood Culture(most relevant for therapy selection)
- Synergistic Effect is seen w/ Beta Lactams + Aminoglycosides
- not necessarily good as toxicity is increased and recent studies showed that there was no
increase in efficacy when the two drugs were administered
- Cephalosporin may induce beta lactamase production by some organisms
- Adverse effect: Bone Marrow Suppression
- Vancomycin may cause Neutropenia

- Ceph + 2 Beta Lactams should be avoided in Enterobacter infections

Antifungals
- Most Common: Candida sp. & Aspergillus sp.
- Cryptococcus common in Px taking immunosuppressive agents
1. Amphotericin B
a. Systemic Infections
b. For febrile patients despite 4-7 day of antibacterial treatment
c. Rationale for use:
i. Disseminated disease may have already occured before a culture can be obtained
ii. High risk mortality from disseminated fungal infections in granulocytopenic Px
d. Aspergillus terreus resistant to AmphB
2. Capsofungin - an Echinocandin; useful in Aspergillus and -azole resistant Candida strains
3. Fluconazole
- Candida sp.
- NO ACTIVITY against Aspergillus and Non-Albicans Candida

Antivirals
- Acyclovir for HSV