Chapter 082. Infections in Patients with Cancer (Part 10)

Renal and Ureteral Infections Infections of the urinary tract are common among patients whose ureteral excretion is compromised (Table 82-1). Candida, which has a predilection for the kidney, can invade either from the bloodstream or in a retrograde manner (via the ureters or bladder) in immunocompromised patients. The presence of "fungus balls" or persistent candiduria suggests invasive disease. Persistent funguria (with Aspergillus as well as Candida) should prompt a search for a nidus of infection in the kidney.Certain viruses are typically seen only in immunosuppressed patients. BK virus (polyomavirus hominis 1) has been documented in the urine of bone...
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Chapter 082. Infections in Patients with Cancer (Part 10) Chapter 082. Infections in Patients with Cancer (Part 10) Renal and Ureteral Infections Infections of the urinary tract are common among patients whose ureteralexcretion is compromised (Table 82-1). Candida, which has a predilection for thekidney, can invade either from the bloodstream or in a retrograde manner (via theureters or bladder) in immunocompromised patients. The presence of fungusballs or persistent candiduria suggests invasive disease. Persistent funguria (withAspergillus as well as Candida) should prompt a search for a nidus of infection inthe kidney. Certain viruses are typically seen only in immunosuppressed patients. BKvirus (polyomavirus hominis 1) has been documented in the urine of bone marrowtransplant recipients and, like adenovirus, may be associated with hemorrhagiccystitis. BK-induced cystitis usually remits with decreasing immunosuppression.Anecdotal reports have described the treatment of infections due to adenovirus andBK virus with cidofovir. Prevention of Infection in Cancer Patients Effect of the Environment Outbreaks of fatal Aspergillus infection have been associated withconstruction projects and materials in several hospitals. The association betweenspore counts and risk of infection suggests the need for a high-efficiency air-handling system in hospitals that care for large numbers of neutropenic patients.The use of laminar-flow rooms and prophylactic antibiotics has decreased thenumber of infectious episodes in severely neutropenic patients. However, becauseof the expense of such a program and the failure to show that it dramaticallyaffects mortality rates, most centers do not routinely use laminar flow to care forneutropenic patients. Some centers use reverse isolation, in which health careproviders and visitors to a patient who is neutropenic wear gowns and gloves.Since most of the infections these patients develop are due to organisms thatcolonize the patients own skin and bowel, the validity of such schemes is dubious,and limited clinical data do not support their use. Hand washing by all staff caringfor neutropenic patients should be required to prevent the spread of resistantorganisms. The presence of large numbers of bacteria (particularly P. aeruginosa) incertain foods, especially fresh vegetables, has led some authorities to recommenda special low-bacteria diet. A diet consisting of cooked and canned food issatisfactory to most neutropenic patients and does not involve elaboratedisinfection or sterilization protocols. However, there are no studies to supporteven this type of dietary restriction. Counseling of patients to avoid leftovers, delifoods, and unpasteurized dairy products is recommended. Physical Measures Although few studies address this issue, patients with cancer arepredisposed to infections resulting from anatomic compromise (e.g., lymphedemaresulting from node dissections after radical mastectomy). Surgeons whospecialize in cancer surgery can provide specific guidelines for the care of suchpatients, and patients benefit from common-sense advice about how to preventinfections in vulnerable areas. Immunoglobulin Replacement Many patients with multiple myeloma or CLL have immunoglobulindeficiencies as a result of their disease, and all allogeneic bone marrow transplantrecipients are hypogammaglobinemic for a period after transplantation. However,current recommendations reserve intravenous immunoglobulin (IVIg) replacementtherapy for those patients with severe ( Vaccination of Cancer Patients In general, patients undergoing chemotherapy respond less well to vaccinesthan do normal hosts. Their greater need for vaccines thus leads to a dilemma intheir management. Purified proteins and inactivated vaccines are almost nevercontraindicated and should be given to patients even during chemotherapy. Forexample, all adults should receive diphtheria-tetanus toxoid boosters at theindicated times as well as seasonal influenza vaccine. However, if possible,vaccination should not be undertaken concurrent with cytotoxic chemotherapy. Ifpatients are expected to be receiving chemotherapy for several months andvaccination is indicated (for example, influenza vaccination in the fall), thevaccine should be given midcycle—as far apart in time as possible from theantimetabolic agents that will prevent an immune response. The meningococcaland pneumococcal polysaccharide vaccines should be given to patients beforesplenectomy, if possible. The H. influenzae type b conjugate vaccine should beadministered to all splenectomized patients. In general, live virus (or live bacterial) vaccines should not be given topatients during intensive chemotherapy because of the risk of disseminatedinfection. Recommendations on vaccination are summarized in Table 82-2. Further Readings Bohlius J et al: Granulopoiesis-stimulating factors to prevent adverseeffects in the treatment of malignant lymphoma. Cochrane Database Syst Rev3:CD003189, 2004 Gafter-Gvili A et al: Antibiotic prophylaxis for bacterial infections inafebrile neutropenic patients following chemotherapy. Cochrane Database SystRev 4:CD004386, 2005 Hall K et al: Diagnosis and management of long-term central venouscatheter infections. J Vasc Interv Radiol 15:327, 2004 [PMID: 15064335] Paul M et al: Empirical antibiotic monotherapy for febrile neutropenia:Systematic review and meta-analysis of randomized controlled trials. J AntimicrobChemother 57:176, 2006 [PMID: 16344285] Ullmann AJ et al: Posaconazole or fluconazole for prophylaxis in severegraft-ver ...