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به نام يگانه هستي بخش
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دكتر آزرم
Infections in Cancer Patients
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Infections are major
causes of morbidity and mortality in patients with cancer.
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The risk of infection is principally related to the
intensity and duration of immuno-suppressive chemotherapy.
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Immune Defects present in neoplastic diseasesImmune Defects present in neoplastic diseases
1.Impaired phagocytic function.
2.Phagocyte mobilization.
3.Neutropenia.
4.Impaired cell mediated immunity
5.Decreased antibody levels
6.Corticoesteroides therapy
7.Chemotherapy
8.Radiotherapy
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Infection in Patients with CancerInfection in Patients with Cancer
1. Exagenous infection
2. Endageous infection
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Infection in Patients with Cancer
Exagenous infections:
In the hospital setting: Pseudomonas aeruginosa Serratia marcescens
KlebsiellaStaphylococci human carriersEnterococci AspergillusVaricella zoster virus aerosolsRespiratory syncytial v. adenovirusInfluenza virus
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Infection in Patients with Cancer
Endogenous Infections:Endogenous Infections:
Escherichia coliS.Aureus , coagulase neg staph.Candida , Corynebacterium
Gram-Negatiye rods
There are the most common catheter associated pathogens.
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Neutropenia in Cancer Patients
1. Chemotherapy2. Radiotherapy3. Replacement of BM
In acute leukemia, the marrow may be replaced with malignant cells so that virtually no normal circulating neutrophils exist.
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Factors Predisposing to Infection in Patients with Cancer
1.the underlying malignancy . 2.the level of immuno-suppression. 3.Multiple predisposing factors.
These factors may exist in a single patient, thus increasing the spectrum of likely pathogens.
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Clinical Syndromes of Infection
-Septicemia
-High-fever with evidence of cutaneous dissmination.
-Diffuse Pneumonia: Fungal & Viral infections, Parasitic & Bacterial infection
-Central nervous system infections: meningitis Brain abscess Encephalomyelitis
-Oro-esophageal infection
-Diarrheal syndromes
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Septicemia:
The incidence of septicemia is generally increased in cancer patients, this risk is profoundly influenced by the degree of granulocytopenia. when mucositis is present, the risk of sepsis increases.
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Septicemia:
Septicemia resulting from Streptococcus
bovis often occurs in association with a
Gastrointestinal malignancy , particulary
Colon cancer.
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Septicemia:
70% of bacteremias resulting from Clostridium septicum are associated with either Colon cancer or Leukemia.
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Septicemia:
Septicemia with
1. S . aureus2. Coagulase-Negative Staphylococci3. Corynebacterium and 4. Candida
are frequently secondary to infected intravascular devices.
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High-fever with evidence of cutaneous dissmination
Classically , the organisms that result in cutaneus lesions are Staphylococcus aureus and Pseudo.aeruginosa.
In the Neutropenic patients ,however, purulent inflammation is often absent.
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Diffuse Pneumonia:
Cancer patients who present with diffuse intersitial pneumonia must urgently evaluated particularly when the illness is accompanied by evidence of arterial hypoxemia.
1.Fungal infections: P. Carini.
2.Parasitic infections : Toxo.gondii.
3.Viral infections: Herpes viruses
4.Bacterial: any gram negative or positive Nocardia , mycobactrium & chlamydia.
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Central Nervous System Infections
1.Meningitis
2.Brain Abscess
3.Encephalomyelitis
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Meningitis:
1. Streptococcus pneumoniae
2. H.Influenzae
3. N. Meningitidis Constitute 70% of the bacterial meningitis.
Approximately one third of CNS infections in
Cancer patients are FUNGAL with Candida.
Neoformans. L.monocytogenes most
common bacterium meningitis in the
immunocompromised host.
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Brain AbscessBrain Abscess
Opportunistic patogens in almost three quarters of cancer patients develop a brain abscess.
Nocardia and Aspergillus are frequent.
In whom the most common causes are gram
positive Cocci, such as S.aureus, Streptococci
and anuerobes
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Encephalomyelitis
Diffuse paranchymal invasion of the CNS.
• Herpes Viruses
• T. gondii
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Patients with untreated Hodgkin's disease have significant abnormalities in T-cell number and function, which persist in the majority of long-term survivors.Increased risk for toxoplasmosis, nocardiosis, pneumocystosis, cryptococcosis, mycobacterial infections, and herpes zoster. patients were receiving corticosteroids, myeloablative chemotherapy, or both.
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Exit-site infections:
Percutaneous infections are most common, in the form of cellulitis at the insertion site ( exit-site infections ) or deeper in the subcutaneous track of the catheter ("tunnel" infections). Exit-site infections occur at the skin wound, which is the catheter insertion site, or in the case of subcutaneous ports, the needle access site.
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The organisms infecting ( exit-site
infections ) are most commonly
derived from the patient's skin flora
or from the hands of health care
workers.
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exit-site infections:
Tenderness and erythema and purulent discharge and are most commonly caused by Staphylococcus epidermidis.
The site should be cultured and treated with topical antibiotic ointment. The ( Line ) can usually be left in place unless the infection is due to Pseudomonas species or atypical mycobacteria.
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Catheters Hickman line and Ommaya
reservoirs, Foley Tube are potential
niduses of infection.
Patients with malignancy commonly
experience malnutrition , which
increases the risk of infection.
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Patients with chronic lymphocytic leukemia(CLL) frequently have hypogammaglobulinemiaor dysglobulinemia.
Low levels of both :
1. IgG
2. Specific antibodies to pneumococcal
polysaccharide capsule are associated with an
increased rate of infections in these
patients.
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Diarrheal Syndromes
The onset of diarrhea is frequently by :
Salmonella
Shigella
Campylobacter
Clostridium difficile
Mixed bowel flora Fever & diarrhea
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Patients with hairy cell leukemia appear to
have a defect in cell-mediated immunity,
leaving them prone to develop an unusually
high frequency of opportunistic atypical
mycobacterial infections.
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Patients with multiple myeloma and
other related gammaglobulinopathies
also are often have functionally and
hypo gamma globulinemia.
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Early and advanced Stage of disease:
1- Early Stage:
S. pneumoniae and Haemophilus influenzae.
2- Advanced disease :
Post responding to chemotherapy,
infections by Staphylococcus aureus and gram-
negative pathogens.
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Oro esophageal infection
Oropharynx and the esophagus infections
are common in Neoplastic patients.
Highly Symptomatic:
1.Impaired Neutrition
2.Difficulty in swallowing , and substernal burnining.
3.Candida , Gram positive , Anaerobic infection
4.Immunodificiency
5.Antibiotics
6.Anti cancer agents
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Clinical approach to the patientClinical approach to the patient
Fever evaluated
Change in mental status
Presence of Agitation
Hemodynamic instability
Presence new Cutaneous lesion
Multiple blood cultures , Cultures of local sites.
Routine blood test ……., Transaminase …..
Chest radiograph , Serologic tests
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Mucosal Immunity
The mucosal linings in the gastrointestinal, sino-pulmonary, and genitourinary tracts constitute the first line of host defense against a variety of pathogens.
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Mucosal Immunity
Chemotherapy and radiation therapy cause
defects in mucosal immunity at several different
levels.
The physical protective barrier conferred by the
epithelial lining is compromised, thus allowing
access to colonizing microflora.
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In BMT patients, chronic graft-versus-host disease (GVHD) further compromises mucosal immunity.
These patients have defective salivary
immunoglobulin secretion and corticosteroids
profoundly compromise mucosa-associated
lymphoid tissue by inducing apoptosis of M cells and
depleting lymphoid follicles of T and B cells.
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Diagnostic studies fail to Diagnostic studies fail to
disclose the cause of fever in disclose the cause of fever in
50 to 80% of febril patients.50 to 80% of febril patients.
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Treatment of febrile Neutropenic patientTreatment of febrile Neutropenic patient
The combination of1-Aminoglycoside: Gentamycin or Amikacin.
2-Anti pseudomonal agents:(Ticarcillin) , Cephalosporine ( Ceftazidime) or Carbapenem ( Imipenem , Meropnem )
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The risk of invasive aspergillosis is also
directly related to the period of neutropenia.
In patients with leukemia, showed that
aspergillosis was uncommon when
neutropenia lasted for less than 14 days.
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Use of Vancomycin
Vancomycin is most appropritely intiated
when Staphyloccoccal or alpha-hemolytic
organism are recovered from cultures.
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Thank you for your
attention T.Azarm M.D.
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