Chapter 49 Complications After Hematopoietic Stem Cell Transplantation
Mo, Month; UCB, umbilical cord blood.
CMV, Cytomegalovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; HCT, hematopoietic cell transplantation; HLA, human leukocyte antigen; PTLD, posttransplant lymphoproliferative disorder; TMP-SMX, trimethoprim-sulfamethoxazole; wk, week.
|Pathogen||Preventing Early Disease (0-100 Days After HCT)||Preventing Late Disease (>100 Days After HCT)|
|Bacterial infections||No specific recommendations*||Antibiotics (based on local resistance patterns) to prevent infections due to encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis) in patients on chronic immunosuppression|
|Cytomegalovirus||Prophylaxis or preemptive treatment with ganciclovir or valganciclovir in high-risk patients†||Preemptive treatment with ganciclovir or valganciclovir in high-risk patients†|
|Herpes simplex virus||Acyclovir in seropositive patients||Acyclovir in patients with recurrent HSV infections|
|Yeast infections||Fluconazole||Fluconazole in patients on chronic immunosuppression|
|Mold infections||No specific recommendations‡||No specific recommendations*|
|Pneumocystis jiroveci||Trimethoprim-sulfamethoxazole (preferred) or dapsone or pentamidine||Trimethoprim-sulfamethoxazole (preferred) or dapsone or pentamidine in patients on chronic immunosuppression|
HCT, Hematopoietic cell transplantation; HSV, herpes simplex virus.
|Vaccine*||Time After HCT to Initiate Vaccine||No. of Doses†|
|Pneumococcal conjugate||3-6 mo||2-3‡|
|Haemophilus influenzae type b conjugate||6-12 mo||3|
|Inactivated poliovirus||6-12 mo||3|
|Recombinant hepatitis B||6-12 mo||3|
|Inactivated influenza||4-6 mo||1-2 yearly‖|
|Measles, mumps, and rubella virus (live)||24 mo||1-2¶|
DTaP, Diphtheria and tetanus toxoids and acellular pertussis vaccine; HCT, hematopoietic cell transplantation.
‡Following the primary series of three pneumococcal conjugate vaccine (PCV) doses, a dose of the 23-valent pneumococcal polysaccharide vaccine (PPSV23) to broaden the immune response might be given. For patients with chronic GVHD who are likely to respond poorly to PPSV23, a fourth dose of the PCV should be considered instead of PPSV23.
¶Not recommended less than 24 months post-HCT, in patients with active GVHD, and in patients on immune suppression. In children, two doses of measles, mumps, and rubella virus vaccine live are favored. Lower viral-dose vaccines (varicella vaccine live [Varivax], not zoster vaccine live [Zostavax]) may be preferred as potentially safer.
1. Seronegative recipient with seronegative donor (allogeneic and autologous): Transfuse only cytomegalovirus (CMV)-safe blood products. Leukocyte depletion by filtration and blood from CMV-seronegative donors are clinically equivalent alternatives.
2. Seronegative recipient with seropositive donor (allogeneic): Deliver only CMV-safe blood products (seronegative or leukocyte depleted), but administer chemoprophylaxis as well to prevent reactivation of donor-derived endogenous virus.