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

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
Chemotherapy
Hodgkin's
Disease
Hematopo
ietic Stem Cell
Transplantation
Diphtheria-
tetanus
a


Primary
series and boosters
as necessary
No special
recommendation
12, 14, and
24 months after
transplantation
Poliomyelitis
b
Complete
primary series and
boosters

No special
recommendation
12, 14, and
24 months after
transplantation
Haemophilus
influenzae
type b
conjugate
Primary
series and booster
for children
Immunizati
on before
treatment and
booster 3 months
afterward
12, 14,
and
24 months after
transplantation
Hepatitis A Not
routinely
recommended
Not
routinely
recommended
Not
routinely
recommended

Hepatitis B Complete
series
No special
recommendation
12, 14, and
24 months after
transplantation
23-Valent
pneumococcal
polysaccharide
c


Every 5
years
Immunizati
on before
treatment and
booster 3 months
afterward
12 and 24
months after
transplantation
4-Valent
meningococcal
conjugate
d


Should be

administered to
splenectomized
patients and
patients living in
endemic areas,
incl
uding college
Should be
administered to
splenectomized
patients and
patients living in
endemic areas,
including college
Should be
administered to
splenectomized
patients and
patients living in
endemic areas,
including college
students in
dormitories
students in
dormitories
students in
dormitories
Influenza Seasonal
immunization
Seasonal

immunization
Seasonal
immunization
Measles/mumps/r
ubella
Contraindic
ated
Contraindi
cated during
chemotherapy
After 24
months in patients
without graft-
versus-host
disease
Varicella-zoster
virus
Contraindic
ated
e

Contraindi
cated
Contraindi
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 current
ly
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 wi
th
acute lymphocytic leukemia.