The Cancer Nutrition Network for Texans

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Consumer Alert / Therapeutics

Problem: Infection

Symptoms / Recognition:
Symptoms depend on the etiology of the organism and the status of the patient’s immune system. Chemotherapy patients may not display the ‘classic’ features of infection secondary to immunocompromise. Some of the more common symptoms are: fever, chills, rigor, tachycardia, tachypnea, hypotension, diaphoresis, nausea, vomiting, diarrhea, confusion, stupor and oliguria.

Goal:
Quickly identify the causal organism and administer the appropriate antimicrobial. Administer treatment to stabilize the patient’s vital signs, if necessary.

Pathogenesis:
The lowest WBC counts usually occur 10-14 days after treatment. Cell counts usually return to normal by 3-4 weeks. Absolute granulocyte counts lower than 1500/ cu mm places the patient at greatest risk for fever and sepsis.

Normal Barriers to Infections
Type of
Defense		 Specific
Lesions		 Cells Involved Organisms Cancer
Association		 Disease
Physical barrier Breaks in skin Skin epithelial cells Staphylococci, streptococci Head and neck, squamous cell carcinoma Cellulitis, extensive skin infection
Emptying of fluid collections Occlusion of orifices: ureters, bile duct, colon Luminal epithelial cells Gram-negative bacilli Renal, ovarian, biliary tree, metastatic diseases of many cancers Rapid, overwhelming bacteremia, urinary tract infection
Lymphatic disease Node dissection Lymph nodes Staphyloccoci, streptococci Breast cancer surgery Cellulitis
Splenic clearance of microorganisms Splenectomy Splenic reticuloendothelial cells Streptococcus oneumoniae, Haemophilus influenzae, Neisseria meningitidis, Babesia, Capnocytophaga canimorsus Hodgkin's disease, leukemia, idiopathic thrombocytopenic purpura Rapid, overwhelming sepsis
Phagocytosis Lack of granulocytes Granulocytes (neutrophils) Staphylococci, streptococci, enteric organisms Hairy-cell, acute myelocytic, and acute lymphocytic leukemias Bacteremia
Humoral immunity Lack of antibody B cells S. pneumoniae,
H. influenzae, N. meningitidis		 Chronic lymphocytic leukemia Infections with encapsulated organisms, sinusitis, pneumonia
Cellular immunity Lack of T cells T cells and macrophages Mycobacterium tuberculosis, Listeria, herpesviruses, fungi, other intracellular parasites Hodgkin's disease, leukemia, T cell lymphoma Infections with intracellular bacteria, fungi, parasites

Infections and Cancer
Cancer Underlying Immune Abnormality Organisms Causing
Infection
Multiple myeloma Hypogammaglobulinemia Streptococcus oneumoniae,
Haemophilus influenzae,
Neisseria meningitidis
Chronic lymphocytic leukemia Hypogammaglobulinemia S. pneumoniae, H. influenzae, 
N. meningitids
Acute myelocytic or lymphocytic leukemia Granulocytopenia, skin and mucous-membrane lesions Extracellular gram-positive and gram-negative bacteria, fungi
Hodgkin's disease Abnormal T-cell function Intracellular pathogens (Myobacterium tuberculosis, Listeria, Salmonella, Cryptococcus, Mycobacterium avium)
Non-Hodgkin's lymphoma and acute lymphocytic leukemia Steriod chemotherapy, T- and B-cell dysfunction Pneumocystis carinii
Colon and rectal tumors Local abnormalities*` Streptococcus bovis (bacteremia)
Hairy-cell leukemia Abnormal T-cell function Intracellular pathogens (M. tuberculosis, Listeria, Cryptococcus, M. avium)

Table 87-4

Organisms Likely to Cause Infections in Granulocytopenic Patients
Gram-positive cocci

Staphylococcus epidermidis
Staphylococcus aureus
Viridans Streptococcus
Enterococcus faecalis
Streptococcus pneumoniae

Gram-negative bacilli

Escherichia coli
Klebsiella species
Pseudomonas aeruginosa
Non-aeruginosa Pseudomonas species
Enterobacter species
Serratia species
Acinetobacter species
Citrobacter species

Gram-positive bacilli

Diphtheroids
JK bacillus

Fungi

Candida species
Aspergillus species

Therapeutic Stratagem:
The lab tests that may need to be ordered on a patient will vary depending on the symptoms at presentation. Of course, it is paramount to perform a through physical exam and history. Some considerations are:

  1. CBC
  2. Blood cultures (aerobic, anaerobic, fungal, mycoplasmal)
  3. Urine culture
  4. Sputum culture
  5. Stool culture
  6. CSF culture
  7. Chest X-Ray
  8. Remove and culture peripheral and central lines
  9. Culture exudates from wounds (surgical or otherwise)
  10. Abscesses, if present, should be drained and the fluid cultured
  11. If there is no obvious site for infection, a CT may be warranted
  12. Administer antimicrobial therapy. Some consideration for antibiotic therapy are:
    1. Use antibiotics active against both Gram-positive and Gram-negative bacteria.
    2. An aminoglycoside or a quinolone alone is not adequate in the chemotherapy patient.
    3. The antibiotic chosen should reflect both the epidemiology and the antibiotic resistance pattern on the hospital.
    4. A single third-generation cephalosporin constitutes an appropriate initial regimen in many hospitals.
    5. Most standard regimens are designed for patients who have not previously received prophylactic antibiotics. If antibiotics are ready in use, it is necessary to gather the resistance profile of the bacteria and select a specific antibiotic against it.
    6. Once the sensitivities of the bacteria are known, tailor the treatment accordingly.
  13. Fungal infections
    1. Commonly due to Candida and Aspergillus
    2. Add Amphotericin B if patients remain febrile after 4-7 days of antibiotic treatment.
  14. Consider immunizations:

Vaccination of Cancer Patients Receiving Chemotherapy

Use in Indicated Patients
Vaccine Intensive
Chemotherapy		 Hodgkin's
Disease		 Bone Marrow Transplantation
Diphtheria-tetanus (diptheria, pertussis, tetanus; DPT) for children <7 years old Primary series and boosters as necessary No special recommendation 12 and 24 months after transplantation
Poliomyelitis* Complete primary series and boosters No special recommendation 12 and 24 months after transplantation
Haemophilus influenzae type b Primary series and booster for children Immunization before treatment and booster 2 years afterward 12 and 24 months after transplantation
23-Valent pneumococcal Every 6 years Immunization before treatment and booster 2 years afterward 12 and 24 months after transplantation
4-Valent meningococcal Every 6 years Immunization before treatment and booster 2 years afterward 12 and 24 months after transplantation
Influenza Seasonal immunization Seasonal immunization Seasonal immunization
Measles/mumps/rubella Contraindicated Contraindicated After 24 months in patients without graft-versus-host disease
Varicella-Zoster virus Contraindicatedº Contraindicated Contraindicated
* Live virus vaccine is contraindicated; inactivated vaccine should be used.

º Contact the manufacturer for more information on use in children with acute lymphocytic leukemia.

This list is by no means all-inclusive. The presentation of the patient will dictate what measures should be taken.

Baseline and Serial Monitoring:
Continue to monitor the patient’s vital signs throughout the infection. Remember that severely immunocompromised patients may not be able to mount an immune response, so some of the classical signs of infection (e.g. fever) may not be present.

Sentinel Events:
Severely ill patients may present with sepsis (fever >38C or hypothermia <36C, tachycardia >90 bpm, and tachypnea >20 bpm, PaCO2 of < 32mmHg, leukocyte count of >12, 000 or <4,000) or septic shock (sepsis with hypotension and organ dysfunction). Hyperventilation is often an early sign as are signs of disorientation and confusion. Major complications include: ARDS, oliguria, azotemia, proteinuria, and DIC.

Outcome Markers
Once the etiology of the infection has been identified and treated, the patient should remain afebrile without other system dysfunction or signs of infection.

Resources:

  • Harrison's Principles of Internal Medicine 14th Edition
  • The Washington Manual of Medical Therapeutics 29th Edition

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