CHAPTER 50. Prophylactic Vaccination of Cancer Patients and Hematopoietic Stem Cell Transplant Recipients by William Decker and Amar Safdar

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ABSTRACT

Prophylactic immunization in cancer patients is safe and cost-effective in reducing the disease burden and complications arising from vaccine preventable infections. For maximal effectiveness, patients should be vaccinated with inactivated vaccines at least two weeks prior or three months subsequent to myeloablative chemotherapy.  Hematopoietic stem cell transplant recipients should similarly be vaccinated 6-12 months posttransplant, immune reconstitution permitting.  Vaccination of patients with B-cell malignancies is more problematic but difficulties can be somewhat ameliorated by applying higher doses of vaccine in greater frequencies than would be typical for immunocompetent individuals.  Live vaccines are typically considered to be unsafe for oncology patients, but may be safely administered to HSCT recipients who are > 2 years posttransplant.  While many common infections can be managed through a strategy of conscientious vaccination, there are many other serious infections that specifically afflict immunocompromised patients populations and for which effective vaccines do not yet exist.  While vaccines that will address some of these infectious conditions are currently in development, it is unlikely that all important oncological infections will ultimately be addressed by a vaccine approach as market-based development strategies are unlikely to target infections with a negligible impact upon immunocompetent populations.  In this chapter we present an comprehensive review of vaccination in oncology patients.

CHAPTER 49. Prevention of Tropical and Parasitic Infections: The Immunocompromised traveler by Francesca F. Norman and Rogelio López-Vélez

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ABSTRACT

The number of immunocompromised travelers is increasing and persons with significant pre-existing medical conditions may be exposed to infectious diseases at their destination of choice. The risks of developing severe disease are increased and adivising these complex patients may be challenging for health care professionals. Recommendations for prevention of specific travel-related infections and vaccination in immunocompromised patients as well as general advice for the cancer patient wishing to travel are outlined.

CHAPTER 48. Infection prevention – protected environment and infection control by J. Peter Donnelly

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ABSTRACT

In our daily life, we all encounter a range of microorganisms by breathing, eating and drinking and by direct contact with each other and the objects around us. This routine occasionally leads to infection. By contrast, patients who are given chemotherapy to treat cancer can succumb dramatically when confronted with these commonplace infections. Moreover when death ensued it was all the more tragic since in many cases it might have been avoided altogether had effective treatment been instituted early enough or, better still, if the infection had been prevented in the first place. In this chapter an overview of infection control measures including protected environment for severely immunocompromised cancer patients is presented.

CHAPTER 47. Controversies in Antimicrobial Prophylaxis by Ben de Pauw and Marta Stanzani

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ABSTRACT

The risk of life threatening infection in association with chemotherapy induced neutropenia coincided miraculously with the development of a second generation of antimicrobial agents. Even after having randomized more than 10,000 patients in clinical trials on prophylaxis during neutropenia there is still no convincing scientific evidence to support the apparently attractive strategy. Even trials that at first glance appear to provide a positive answer don’t survive a meticulous dissection. Two major factors are accountable for this unfortunate situation: a lack of trials with an adequate number of patients and a shortage of reliable diagnostic tools to establish infections in neutropenic patients. Meta-analysis has become a fashionable approach to meet the problem of low numbers to a certain extent but the outcome has to be interpreted with caution. Trials that do not include statistically significant findings tend to be rejected by peer-reviewed journals, which may lead to an overestimation of the prophylactic effect. A comprehensive discussion of controversies related with antimicrobial prophylaxis is provided in this chapter.

CHAPTER 46. Antibacterial, Antifungal and Antiviral Prophylaxis in High-Risk Cancer and Stem Cell Transplant Population by Marcio Nucci and John R. Wingard

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ABSTRACT

Infection represents a major cause of morbidity and mortality in hematopoietic stem cell transplant (HSCT) recipients and cancer patients. Antimicrobial prophylaxis is justifiable in these immunosuppressed patients, but its benefits may be offset by potential problems such as the selection for resistant organisms, an increase in toxicity and cost. Therefore, any attempt to administer an antimicrobial agent should be accompanied by a reflection of the potential benefits and risks of prophylaxis. This chapter reviews the rationale and current recommendations for antimicrobial prophylaxis of infections in HSCT recipients and in high-risk cancer patients, the later group represented mostly by patients with hematologic malignancies, including those with acute leukemia, multiple myeloma and lymphoma.

CHAPTER 45. Prevention of Antimicrobial Resistance: Current and Future Strategies by Cesar A. Arias and Adolf W. Karchmer

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ABSTRACT

Antibiotic-resistant organisms are now commonly found in centers dedicated to the care of cancer patients, but most worrisome, have been increasingly reported as a cause of serious infections in community settings, even in healthy individuals with no apparent contacts with the health system. The discovery and development of antimicrobial agents is one of the most significant advances in the history of clinical medicine. The delivery of aggressive invasive and immunosuppressive medical care, as occurs with cutting edge therapies today, will not be possible in the absence of effective antimicrobial agents. This concept is particularly crucial in the care of cancer patients who receive complex chemotherapeutic regimens that damage their immune system.  The emergence of increasingly multi-drug resistance bacteria is a limiting challenge to successful cancer therapy and is accentuated by the absent development of new antimicrobials that are active against the most recalcitrant bacterial species. A concerted and integrated effort among clinicians, hospital epidemiologists, academic medical centers, pharmaceutical companies and government agencies is essential if the “tide’ of antimicrobial resistant microorganisms that threaten the future of modern medical care is to be arrested.

Chapter 44. Controversies in Antimicrobial Stewardship by Graeme N. Forrest

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ABSTRACT

Antimicrobial stewardship programs are recommended by the Infectious Diseases Society of America as a method to control antimicrobial costs and resistance. These programs are usually implemented hospital wide, but there is little evidence on their effects in oncology units. Three controversial areas of antimicrobial stewardship in oncology units include whether these programs decrease antimicrobial resistance when antimicrobial restriction is implemented, the role of antimicrobial cycling on Gram-negative resistance and that these programs rarely control outpatient antimicrobial therapy. This review will discuss these controversial areas with regard to the evidence, strength of trial design and the generalizability of their outcomes.

Chapter 43. Antimicrobial Stewardship: Considerations for a Cancer Center by Cora Mihu, Alla Paskovaty, Susan K. Seo

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ABSTRACT

Since the discovery of penicillin, unbridled enthusiasm for antibiotics has led to their extensive application in medicine, animal care, and agriculture. Injudicious antimicrobial use has also contributed to the emergence and spread of multidrug-resistant bacteria, creating a situation in which there are few or no treatment options for infections due to these organisms.  There is increasing awareness that antimicrobial resistance adversely impacts patient safety and public health.  In essence, effective antimicrobial stewardship entails the optimal selection, dose, and duration of an antibiotic, resulting in the cure of an infection with minimal toxicity to the patient and minimal impact on selective pressure. A detailed discussion on this important issue is presented in this chapter.

CHAPTER 42. Zoonoses in Cancer Patients by Donald Armstrong

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ABSTRACT      

Prevention of zoonoses in cancer patients is the theme of this chapter and it is hoped that it will encourage and help doctors caring for such patients to educate them to avoid the infections. Avoidance need not include seperation from a pet or occupation or recreation, but the use of caution conditioned by knowledge of the sources of infection and the ways we contact them should lead to effective prevention.

CHAPTER 41. Parasitic Infections in Cancer Patients: Toxoplasmosis, Strongyloidiasis, and Other Parasites by Brian G. Blackburn and José G. Montoya

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ABSTRACT

The most important parasitic infections in cancer patients are Toxoplasma gondii and Strongyloides stercoralis.  Both can cause life-threatening disease in immunocompromised patients, where T. gondii can present as encephalitis, pneumonia, fever of unknown origin, myocarditis, hepatitis, and chorioretinitis, and S. stercoralis as the disseminated hyperinfection syndrome.  Effective therapies are available for both, but high case-fatality rates result if these syndromes are not recognized and treated promptly.  Excellent preventative measures are available for both parasites, including prophylactic anti-Toxoplasma therapy or ivermectin treatment for strongyloidiasis in properly selected patients.  Identifying cancer patients at risk for these syndromes is therefore critical, so that these measures can be instituted before life-threatening disease develops.