Table 4.

Host Immune Deficits and Infections Associated with Immunosuppressive and Chemotherapeutic Agents

Agent Class	Effects on Immune System	Associated Pathogens
Corticosteroids	Decrease chemotactic activity to sites of inflammation; Inhibition of phagocytic, microbicidal, and T cell functions	Herpes virus, Candida sp. bacteria, P. jirovecii
Cytotoxic Drugs: methotrexate, f-fluorouracil (antimetabolites) cyclophosphamide, chlorambucil, melphalan (alkylating agents), doxorubicin, daunorubicin, idarubicin, mitoxantrone (anthracyclines), vincristine, vinblastine, cisplatin, bleomycin	Suppress bone marrow and significantly reduce counts at high doses; neutropenia; some cause lymphopenia, some cause significant mucositis	Bacteria (gram positive and negative), Candida, invasive mold infection with prolonged neutropenia
Purine analogs (eg. fludarabine, cladribine, pentostatin)	Neutropenia, lymphopenia, ± hypogammaglobulinemia	Encapsulated, gram positive, gram negative bacteria Herpesviruses (HSV, VZV, CMV), mycobacteria, Candida, Aspergillus, Cryptococcus
Azathioprine	Inhibits B and T cell proliferation, decreased antibody production, myelosuppresssion	Bacterial infections (leukopenia), herpes zoster, CMV, JC virus (PML*) hepatitis virus B and C exacerbation, P. jirovecii, Nocardia
Cyclosporine, tacrolimus	Inhibit production of IL-2 and other cytokines by CD4- positive T cells	CMV, EBV PTLD, JC virus (PML), BK polyomavirus nephropathy, hepatitis C virus reactivation
Mycophenolate mofetil	Inhibits B and T cell proliferation; decreased antibody production; leukopenia	Herpesviruses (HSV, VZV, CMV), hepatitis C virus and B virus reactivation, JC virus (PML), Candida mucocutaneous disease, P. jirovecii, Cryptococcus, Aspergillus, Mucor
Rapamycin (sirolimus) Everolimus	Inhibition of T cell activation and proliferation; inhibition of antibody production	Herpesviruses (HSV, VZV, CMV), Pneumocystis jiroveci pneumonia, EBV-associated PTLD**, BK polyomavirus nephropathy, JC virus (PML), Tuberculous and non-tuberculous mycobacterial infections
Other: Phenytoin	IgA deficiency or hypogammaglobulinemia	Bacteria (including encapsulated bacteria), respiratory viruses, enteroviruses, Giardia

^*PML, progressive multifocal leukoencephalopathy;

^**PTLD, post-transplant lymphoproliferative disease