Information
Editors
Infections in Immunocompromized Children
Essentials
- Early recognition of
- sepsis or risk of it
- severe viral illnesses
- Pneumocystis jirovecii pneumonitis.
Centralization of treatment
- Cytostatic treatment for children is provided by hospitals with paediatric haemato-oncologists or oncologically trained paediatricians. Therefore, families have been advised to contact directly the hospital responsible for the treatment of their child.
Suspected bacterial infection
- Fever (> 38°C) in a neutropenic child is always a serious sign: the child should be immediately referred to the nearest paediatric hospital. If the blood neutrophil count is below 0.5 × 109 /l, fever is always an indication to start broad-spectrum antimicrobial treatment at hospital after the blood culture samples have been taken.
- Abdominal pain and diarrhoea can also be the first symptoms of sepsis.
- Focal infections without fever (otitis, sinusitis) can be treated normally if the general condition of the patient is good. Suspect septicaemia also in a non-febrile patient with deteriorated general condition.
Viral infections
- If a child with leukemia, lymphoma or congenital or acquired immunodeficiency comes into contact with a person with chickenpox, therapy with VZV immunoglobulin is indicated. In addition to the immunoglobulin, acyclovir may be added to the therapy.
- Published data on the efficacy of acyclovir in preventing disease in immunocompromised individuals are rather scarce.
- A symptomatic chickenpox or shingles in such a child, however, should always be treated in a hospital with acyclovir.
- Zoster hyperimmunoglobulin (2 ml i.m. for children weighing < 20 kg, 4 ml i.m. for heavier children) if the patient has not had chickenpox.
- As far as possible, the prophylaxis should be administered within 48 hours from transmission, but it may be administered at discretion up to 10 days from transmission.
- The immunoglobulin is of no benefit it the disease has already broken out.
- Acyclovir prophylaxis is started 7 to 9 days from the exposure and it lasts for 7 days. In deep immunosuppression the medication may at discretion be continued for up to day 21 counted from the time of exposure.
- Drug alternatives:
- Valacyclovir 60 mg/kg/24 h p.o. divided into 3 doses, maximum dose 3 000 mg/24 h (250 mg and 500 mg tablet strengths) or
- Acyclovir 80 mg/kg/24 h p.o. divided into 4 doses, maximum dose 3 200 mg/24 h.
- In influenza infection, oseltamivir medication started within 48 hours from symptom onset is recommended.
- Concerning the treatment of other viral infections presenting as respiratory infections or with gastrointestinal symptoms, the specialist unit responsible for the treatment of the immunocompromised patient should be consulted.
- The treatment of a non-febrile viral infection is principally based on symptomatic supportive therapy.
Fungal infections
- A fungal infection should be suspected and empirical treatment started if fever persists in a neutropenic patient despite broad-spectrum antimicrobial treatment.
- Children who are the most severely immunosuppressed, e.g. those who have received stem cell transplantation, have prophylactic antifungal medication.
Pneumocystis jirovecii
- Most children with cancer chemotherapy have sulpha-trimethoprim prophylaxis to prevent P. jirovecii pneumonia.
- A patient with rapid and shallow breathing, even if with only a low-grade fever, should be admitted without delay to a hospital for chest x-ray and arterial blood oxygen measurement.
- The diagnosis is confirmed by BAL samples, induced sputum specimen, or lung biopsy.
- Treatment is carried out with sulpha-trimethoprim 20 mg/kg i.v. (calculated according to trimethoprim) or pentamidine 4 mg/kg i.v. once daily for 14-21 days.
- In moderately severe and severe infections, supportive therapy with prednisone is recommended.
- For children over 13 years of age, 80 mg/day divided into 2 doses for 5 days, thereafter 40 mg/day on day 6-10 and 20 mg/day on days 11-21.
- For smaller children, 1 mg/kg twice daily for 5 days, then 0.5 mg/kg twice daily for 5 days and thereafter 0.5 mg/kg once daily on days 11-21.
- In a severe infection, an arterial cannula and, as necessary, oxygen therapy (mask/CPAP/respirator) are needed.
Splenectomized children
- Splenectomized children are usually vaccinated against Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae already before the operation. Consult local guidance for further details on the possible need for booster vaccinations. Vaccination against influenza is recommended.
- High fever in a splenectomized child is always a severe symptom and requires prompt assessment by a physician.
References