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INTRODUCTION

Key Clinical Questions

  • image What is the approach to an immunocompromised patient with suspected infection?

  • image What are common infectious complications in patients receiving chronic corticosteroids, or recently treated with tumor necrosis factor inhibitors or rituximab?

  • image Should preventative measures be taken to prevent infectious complications in patients taking these medications?

  • image What infectious complications are common among patients who have undergone splenectomy?

  • image How should a transplant patient presenting with possible infection be evaluated?

With the advent of newer immunosuppressive medications and the rise in organ transplantation internationally, the numbers of immunocompromised patients are increasing. The diagnosis and management of infection in this growing population is challenging. In immunocompromised patients, the usual signs and symptoms of infection may be obscured, and they often have a higher burden of pathogens and disseminated infection, leading to worse outcomes. These patients are also prone to infection with a broad array of less familiar pathogens, including opportunists such as Listeria monocytogenes and Pneumocystis jiroveci, and latent pathogens such as cytomegalovirus (CMV), toxoplasma, and Mycobacterium tuberculosis, as well as typical community-acquired and nosocomial microbes.

GUIDING PRINCIPLES

Two pieces of information are essential to the care of the patient with impaired immunity: the patient’s epidemiologic exposures and overall state of immunosuppression.

The net state of immunosuppression is determined by the type, intensity, and duration of immunosuppression (including the dose and number of immunosuppressive agents or the presence of innate immunodeficiencies); anatomic factors causing a mechanical breakdown in the host defenses, such as abnormal lymphatic drainage at the site of previous surgery or radiation; and the presence or absence of immunosuppressive infections such as human immunodeficiency virus (HIV) or CMV.

Patients should be questioned about epidemiology that places them at risk for specific pathogens. These include recent events (sick contacts, animal exposure, travel, consumption of undercooked meat or unpasteurized dairy products), as well as remote residence in countries where tuberculosis is endemic, or regions of the United States and the world where histoplasmosis, blastomycosis, or coccidioidomycosis are endemic.

MEDICATION-RELATED IMMUNODEFICIENCY

Dozens of medications, used in a wide variety of medical conditions, may impair immunologic function; an abbreviated list is shown in Table 204-1. Some agents, such as corticosteroids and alemtuzumab, undermine several layers of host defenses. Others have a more targeted effect, such as tacrolimus and cyclosporine, which prevent normal T lymphocyte responses to immunologic stimuli. Understanding the impact of medications on immunity helps to predict which infections the host may develop. In particular, with the availability of novel immunosuppressive targeted or biologic agents such as ibrutinib, tocilizumab, eculizumab, and others, particular attention should be paid to the mechanism of the immunosuppressive agent in order to understand the potential effect on host immunity. For example, the infectious complication that has been most often linked to the C5 complement inhibitor eculizumab is meningococcal infection, similar to what is ...

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