Antimicrobial prophylaxis and surveillance in HSCT patients

Antimicrobial prophylaxis and surveillance in HSCT patients
Policy Details Comments

BMT pre-engraftment
Antibiotic prophylaxis No antibiotic prophylaxis is given  
Surveillance culture Stool surveillance culture for multidrug resistant bacteria in stool and throat swab samples may be done to detect colonization with MDR bacteria. Note this should not be used to initiate prophylaxis This detects ESBL, AmpC, carbapenemase producers, MRSA and VRE. However patients colonized with resistant pathogens should not be presumed to be the only cause of fever without microbiological confirmation
Surveillance PCR for MDRO colonization Stool and throat swab samples from patients may be screened for the presence of genes indicating colonization with MDR bacteria These real-time PCR or end point multiplex PCR based tests can detect NDM, OXA-48, KPC, IMP-1 and VIM genes associated with carbapenem resistance and mecA genes and VanA or vanB genes encoding for MRSA and VRE respectively.
Antifungal prophylaxis Posaconazole This may be administered IV/oral. Blood levels may be monitored if TDM (Therapeutic Drug Level) monitoring facilities are present. If posaconazole is contraindicated then alternative agents include liposomal Amphotericin or an echinocandin (e.g. Micafungin/Anidulafungin)
Antiviral prophylaxis Acyclovir Influenza vaccination Continued in the post transplant period for 6 months for autologous and 1 year for allogeneic BMT.
Yearly vaccination preferably at the beginning of flu season (April-September) and at least 2 weeks before starting chemotherapy
CMV surveillance Haplo and MUD (Matched Unrelated Donor) transplant:
First CMV viral load at D+14, then every 7-14 days depending on risk. Matched sibling transplant:
First CMV viral load at D+28.
If CMV viral load is negative then repeat viral loads are sent based on risk stratification of the underlying disease and previous treatment received. For patients on GVHD treatment: CMV viral load once every 2 weeks. 		Consider pre-emptive therapy if 2 consecutive viral loads (CMV viral load 1000-10,000 copies/mL) are showing an upward trend suggesting possibility of progression to CMV disease.
Start pre-emptive anti-CMV therapy if CMV viral load is high (>10,000 copies/mL).
Start definitive therapy of CMV disease (any viral load) with ganciclovir or valganciclovir.
Note: CMV disease may occur without detectable CMV viremia.
Treatment response assessment once every 2 weeks: clinically as well as based on CMV PCR.
Autologous transplant: no CMV surveillance
     

BMT post engraftment
Antibiotic prophylaxis Stable and engrafted patient:
  • Cotrimoxazole double strength (960 mg) Q12H for twice weekly for 1 year, and
  • Penicillin 400 mg orally Q12H for 1 year.
  • Penicillin prophylaxis in those with splenectomy or those with sickle cell anemia to be continued till 14 years.
  • Penicillin prophylaxis in those patients who have not taken Pneumococcus, Haemophilus and Meningococcal vaccination
Vaccination following splenectomy or functional asplenia PNEUMOCOCCAL CONJUGATE VACCINE (13-valent) followed by (at least 8 weeks later by PNEMOCOCCAL POLYSACCHARIDE VACCINE (23 valent) 0.5ML VACCINE) (0.5 ML intra-muscular upper arm) X 1 stat. Haemophilus influenzae vaccine 0.5ML INJ. (0.5 ML intra-muscular upper arm) X 1 stat: to be given intramuscularly into the upper arm or antero-lateral thigh. A reinforcing (booster) dose of Hib vaccine is recommended at 12 months. Influenza vaccine 0.5ML vaccine: (0.5 mL) X 1 stat. To be administered yearly at the beginning of the Influenza season every year; given by intramuscular injection should be given preferably into the upper arm. Meningococcal vaccine ACWY 0.5mL vaccine (0.5 mL) X 1 stat; All meningococcal-containing vaccines are given intramuscularly into the upper arm or anterolateral thigh. VACCINES should be taken (Pneumococcal + Hib+Influenza+meningococcus) at least 14 days prior to the splenectomy or 14 days after splenectomy. All could be administered simultaneously into different limbs. Individuals with a bleeding disorder should be given vaccine by deep subcutaneous injection to reduce the risk of bleeding.   Re-vaccination with pneumonococcal vaccine may be considered 5 years after primary vaccination.
Antifungal prophylaxis Posaconazole oral syrup: 600-800 mg/ day (200 mg Q8H or Q6H);
Posaconazole IV: Loading dose of 300 mg twice a day on the first day, then 300 mg once a day thereafter.
Liposomal amphotericin B 1 mg/kg/day or 3mg/kg twice weekly.  		 Posaconazole/ liposomal amphotericin B or echnocandin (Micafungin/Anidulafungin) based on oral medication tolerability, requirement of mold active prophylaxis, intolerance to azoles (liver function derangement, hallucination, drug interaction, etc), and presence of GVHD.
Antiviral prophylaxis Yearly Influenza vaccination Yearly vaccination preferably at the beginning of flu season (April-September) and at least 2 weeks before starting chemotherapy. Please note the recommended vaccine composition (northern/southern hemispheric vaccine) from the WHO website updated twice yearly