Management and prophylaxis of infections after BMT/SCT

Management of febrile neutropenia page 357 Empiric antibiotic treatment for febrile neutropenia 357 Management of continued febrile neutropenia in the absence of documented infection (fever of unknown origin) 359 Treatment of specific infections and localizing signs and symptoms of infection 360 Prevention of infections in HSCT patients 366 Antiviral prophylaxis 368 Transplant-related considerations for hepatitis B and C 369 Management of infections 370 Management of specific infections 370 Interstitial pneumonitis 373 Further reading 378 Management of febrile neutropenia Empiric antibiotic treatment for febrile neutropenia Neutropenia as a consequence of cytoreductive chemotherapy is associated with increased risk of serious infections. This risk starts to increase when the absolute neutrophil count (ANC) decreases to less than 1000 cells/mm³ and further increases dramatically when it is less than 500 cells/mm³. A bloodstream infection develops in approximately 10%–20% with neutrophil counts less than 100 cells/mm³. Less often, pneumonia, cellulitis, catheter-related infections, or herpesvirus reactivations occur, causing fever. Fungal infections rarely cause initial fever during neutropenia; they typically occur after a week or more of neutropenia. Notably, fewer than half of all initial episodes of fever and neutropenia are “fever of undetermined origin” (FUO), with no identifiable source of infection despite examination, radiographs, and cultures. FUO patients cannot be reliably distinguished from those with documented infections on presentation, through signs or symptoms or blood tests. Therefore, all neutropenic patients should be treated immediately with a specific regimen of broad-spectrum antibiotics if there is any suspicion of infection, and especially if fever occurs, as there is danger of rapidly progressive sepsis.