Infections in Cancer Patients

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2. Infections in Cancer Patients دكتر آزرم

3. 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 immunosuppressive chemotherapy. Infections are major causes of morbidity and mortality in patients with cancer.

4. 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 immunosuppressive chemotherapy. The riskof infection is principally related to the intensity and duration of immuno-suppressive chemotherapy.

5. Immune Defects present in neoplastic diseases • Impaired phagocytic function. • Phagocyte mobilization. • Neutropenia. • Impaired cell mediated immunity • Decreased antibody levels • Corticoesteroides therapy • Chemotherapy • Radiotherapy

6. Infection in Patients with Cancer • Exagenous infection • Endageous infection

7. Infection in Patients with Cancer Exagenous infections: In the hospital setting: Pseudomonas aeruginosa Serratia marcescens Klebsiella Staphylococci human carriers Enterococci Aspergillus Varicella zoster virus aerosols Respiratory syncytial v. adenovirus Influenza virus

8. Infection in Patients with Cancer Endogenous Infections: Escherichia coli S.Aureus , coagulase neg staph. Candida , Corynebacterium Gram-Negatiye rods There are the most common catheter associated pathogens.

9. Neutropenia in Cancer Patients • Chemotherapy • Radiotherapy • Replacement of BM • In acute leukemia, the marrow may be replaced with malignant cells so that virtually no normal circulating neutrophils exist.

10. Factors Predisposing to Infection in Patients with Cancer • the underlying malignancy . • the level of immuno-suppression. • Multiple predisposing factors. • These factors may exist in a single patient, thus increasing the spectrum of likely pathogens.

11. 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

12. 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.

13. Septicemia: Septicemia resulting from Streptococcus bovis often occurs in association with a Gastrointestinal malignancy , particulary Colon cancer.

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

15. Septicemia: • Septicemia with • S . aureus • Coagulase-Negative Staphylococci • Corynebacterium and • Candida • are frequently secondary to • infected intravascular devices.

16. 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.

17. Diffuse Pneumonia: • Cancer patients who present with diffuse intersitial pneumonia must urgently evaluated particularly when the illness is accompanied by evidence of arterial hypoxemia. • Fungal infections: P. Carini. • Parasitic infections : Toxo.gondii. • Viral infections: Herpes viruses • Bacterial: any gram negative or positive • Nocardia , mycobactrium & chlamydia.

18. Central Nervous System Infections • Meningitis • Brain Abscess • Encephalomyelitis

19. Meningitis: • Streptococcus pneumoniae • H.Influenzae • 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.

20. Brain 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 grampositive Cocci, such as S.aureus, Streptococci and anuerobes

21. Encephalomyelitis • Diffuse paranchymal invasion of the CNS. • Herpes Viruses • T. gondii

22. 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.

23. 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.

24. The organisms infecting (exit-site infections) are most commonly derived from the patient's skin flora or from the hands of health care workers.

25. 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.

26. 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.

27. Patients with chronic lymphocytic leukemia • (CLL) frequently have hypogammaglobulinemia • or dysglobulinemia. • Low levels of both : • IgG • Specific antibodies to pneumococcal • polysaccharide capsule are associated with an increased rate of infections in these patients.

28. Diarrheal Syndromes The onset of diarrhea is frequently by : Salmonella Shigella Campylobacter Clostridium difficile Mixed bowel flora Fever & diarrhea

29. 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.

30. Patients with multiple myeloma and other related gammaglobulinopathies also are often have functionally and hypo gamma globulinemia.

31. 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.

32. Oro esophageal infection • Oropharynx and the esophagus infections arecommon in Neoplastic patients. • Highly Symptomatic: • Impaired Neutrition • Difficulty in swallowing , and substernal burnining. • Candida , Gram positive , Anaerobic infection • Immunodificiency • Antibiotics • Anti cancer agents

33. Clinical 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

34. 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.

35. 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.

36. 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.

37. Diagnostic studies fail to disclose the cause of fever in 50 to 80% of febril patients.

38. Treatment of febrile Neutropenic patient The combination of 1-Aminoglycoside: Gentamycin or Amikacin. 2-Anti pseudomonal agents: (Ticarcillin) , Cephalosporine ( Ceftazidime) or Carbapenem ( Imipenem , Meropnem )

39. 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.

40. Use of Vancomycin Vancomycin is most appropritely intiated when Staphyloccoccal or alpha-hemolytic organism are recovered from cultures.

41. Thank you for your attention T.Azarm M.D.