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دكتر آزرم

Infections in Cancer Patients

Infections are major

causes of morbidity and mortality in patients with cancer.

The risk of infection is principally related to the

intensity and duration of immuno-suppressive chemotherapy.

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

Infection in Patients with CancerInfection in Patients with Cancer

1. Exagenous infection

2. Endageous infection

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

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.

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.

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.

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

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.

Septicemia:

Septicemia resulting from Streptococcus

bovis often occurs in association with a

Gastrointestinal malignancy , particulary

Colon cancer.

Septicemia:

70% of bacteremias resulting from Clostridium septicum are associated with either Colon cancer or Leukemia.

Septicemia:

Septicemia with

1. S . aureus2. Coagulase-Negative Staphylococci3. Corynebacterium and 4. Candida

are frequently secondary to infected intravascular devices.

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.

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.

Central Nervous System Infections

1.Meningitis

2.Brain Abscess

3.Encephalomyelitis

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.

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

Encephalomyelitis

Diffuse paranchymal invasion of the CNS.

• Herpes Viruses

• T. gondii

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.

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.

The organisms infecting ( exit-site

infections ) are most commonly

derived from the patient's skin flora

or from the hands of health care

workers.

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.

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.

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.

Diarrheal Syndromes

The onset of diarrhea is frequently by :

Salmonella

Shigella

Campylobacter

Clostridium difficile

Mixed bowel flora Fever & diarrhea

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.

Patients with multiple myeloma and

other related gammaglobulinopathies

also are often have functionally and

hypo gamma globulinemia.

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.

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

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

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.

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.

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.

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.

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 )

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.

Use of Vancomycin

Vancomycin is most appropritely intiated

when Staphyloccoccal or alpha-hemolytic

organism are recovered from cultures.

Thank you for your

attention T.Azarm M.D.