Table 11.
Ancillary Therapy and Supportive Care Recommendations for Immunologic and Infectious Complications of Chronic GVHD
| Type of Intervention | Recommendation Rating |
|---|---|
| Antibacterial prophylaxis | |
| Antibiotic prophylaxis for encapsulated organisms: | |
| Penicillin Vee-K (if supported by resistance patterns) | BIIb |
| Alternatives: cotrimoxazole, second generation cephalosporins, quinolones and azithromycin | CIII |
| Pneumococcal vaccine | BIIb |
| Hib vaccine | BIIb |
| IVIG routinely after allogeneic HCT | D |
| IVIG in patients with severe hypogammaglobulinemia and repeated sinopulmonary infections | CIII |
| Antibiotic prophylaxis before dental extractions and other invasive procedures | CIII |
| Antifungal prophylaxis | |
| Prophylaxis for Candida infection | CIII |
| Primary prophylaxis with agents with activity against mould if prednisone >0.5–1 mg/kg/day | AIa |
| Secondary prophylaxis with pathogen specific agent for prior history of mold | CIII |
| Pneumocystis jirovecii antibiotic prophylaxis | AIb |
| Antiviral prophylaxis | |
| HSV prophylaxis | D |
| VZV prophylaxis | CIa |
| CMV prophylaxis in seropositive cord blood recipients during the first year after transplantation | CIIa |
| Influenza vaccination with killed vaccine | BIII |
| Early empirical treatment with oseltamivir during influenza outbreaks | CIII |
|
| |
| PEDIATRIC CONSIDERATIONS Children undergoing HCT have frequently missed routine childhood immunizations. Review of immunization history and patient-specific vaccination is indicated. Heptavalent conjugated pneumococcal vaccine is recommended at 12 and 14 mo after HCT for patients less than or equal to 5 yr of age. It is also recommended that children between 2–5 yr of age receive one dose of the 23-valent pneumococcal vaccine 2 mo after the last dose of the heptavalent conjugated vaccine. Patients with primary immunodeficiency diseases (examples: severe combined immunodeficiency disease, Wiskott Aldrich syndrome, IPEX syndrome, and chronic granulomatous disease), regardless of their serum immunoglobulin levels, have never completed a primary immunization series at the time of transplantation. Defects in T cell and B cell collaboration often exist such that serum immunoglobulins may be functionally defective. After transplant, B cell numbers are variably restored; mixed donor T and B cell chimerism may also complicate restoration of functional immunoglobulins. Centers that specialize in HCT for PID typically advocate maintaining serum trough IgG levels of 600 to 800 mg/dL. | |
Hib indicates Haemophilus influenzae type b.