Infections in the Secondary Immunocompromised Host

Abstract

Deficiency in host defences allows infections to occur with greater frequency. Their nature and presentation may be unusual and hence diagnosis may be difficult. The type, severity and duration of immunocompromise determine the infections to which the host is vulnerable. Unlike in primary immunocompromised patients, the susceptibility of secondary immunocompromised patients often changes during the course of their illness as their immune function may vary with the use of immunosuppressive drugs or highly active anti‐retroviral agents prescribed for those with human immunodeficiency virus. There is an ever‐increasing number of new agents that modify the host immune response. These include biologic therapies that target specific cytokines and are used in various inflammatory disorders. The growing numbers of immunocompromised patients make this a key area for those involved in managing infections. A number of strategies are employed to combat the infectious threat ranging from prophylaxis to pre‐emptive, empirical and definitive treatment.

Key Concepts

  • Immunocompromised patients are susceptible to a range of opportunistic infections due to deficiencies in their immune defences.
  • Opportunistic infections occur in immunocompromised but not immunocompetent hosts.
  • Specific immune defects may predispose to a restricted range of opportunistic infections.
  • Immune defects may involve innate (antigen non‐specific) or adaptive (antigen specific) responses.
  • Clinical features may be modified or less apparent in the presence of immunodeficiency.
  • The diagnosis of an infection requires consideration of infectious exposures, details of immunodeficiency and all clinical features and investigation results.
  • Clinical illness may be prevented by screening and treating latent infection, prophylaxis or pre‐emptive treatment in the subclinical phase if markers of infection progression are available.

Keywords: immunocompromised host; opportunistic infection; neutropaenia; transplantation; malignancy; human immunodeficiency virus (HIV); biologic therapies; latent screening; chemoprophylaxis; pre‐emptive treatment

Figure 1. Relationship between post‐stem cell transplant course and susceptibility to specific infections. Risk of infection is based on typical prophylaxis strategies, including co‐trimoxazole for PCP, filtered and screened blood products and ganciclovir for CMV, aciclovir for HSV and fluconazole for candidaemia. (Modified from Marr (2004). © Mosby/Elsevier.)
Figure 2. Chest radiograph of a bone marrow transplant recipient who developed fever and hypoxia. There is indistinct hazy bilateral lower zone shadowing. A bronchoalveolar lavage revealed cytomegalovirus.
Figure 3. Relationship between susceptibility to specific infections and time post‐solid organ transplantation. CMV – cytomegalovirus; EBV – Epstein–Barr virus; PTLD – post‐transplant lymphoproliferative disease; VZV – varicella zoster virus. (Modified from Tolkoff‐Rubin NE & Rubin RH (2004). © Mosby/Elsevier.)
Figure 4. Magnetic resonance imaging (MRI) showing multiple abscesses due to Nocardia in a patient treated with anti‐TNF‐α (infliximab) monoclonal antibody for inflammatory bowel disease.
Figure 5. Abdominal ultrasonogram showing multiple abscesses in the liver in a patient with acute myeloid leukaemia. Biopsy revealed Candida albicans. IVC – inferior vena cava
close

References

Akan H, Anita VP, Kouba M, et al. (2013) Preventing invasive fungal disease in patients with haematological malignancies and the recipients of haematopoietic stem cell transplantation: practical aspects. Journal of Antimicrobial Chemotherapy 68 (Suppl 3): 5–16.

Blau IW and Fauser AA (2000) Review of comparative studies between conventional and liposomal amphotericin B (Ambisome®) in neutropenic patients with fever of unknown origin and patients with systemic mycosis. Mycoses 43: 325–332.

Bodey GP, Buckley M, Sathe YS and Freireich EJ (1966) Qualitative relationships between circulating leukocytes and infection in patients with acute leukaemia. Annals of Internal Medicine 64: 328–340.

Borsato Hauser A, Stingham AEM, Kato S, et al. (2008) Characteristics and causes of immune dysfunction related to uremia and dialysis. Peritoneal Dialysis International 28 (S3): S183–S187.

Browne SK and Holland SM (2010) Anticytokine autoantibodies in infectious diseases: pathogenesis and mechanisms. Lancet Infectious Diseases 10: 875–885.

Centers for Disease Control and Prevention (2013) Guidelines for the prevention and treatment of opportunistic infections in HIV infected adults and adolescents. http://aidsinfo.nih.gov/guidelines (accessed 21.9.14).

Challis JR, Lockwood CJ, Myatt L et al. (2009) Inflammation and pregnancy. Reproductive Science 16 (2): 206–215.

Corti M, Palmero D and Eiguchik K (2009) Respiratory infection in immunocompromised patients. Current Opinion in Pulmonary Medicine 15 (3): 209–217.

Davies JM, Lewis MPN, Wimperis J, et al. (2011) Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: Prepared on behalf of the British Committee for Standards in Haematology by a Working Party of the Haemato‐Oncology Task Force. British Journal of Haematology 155: 308–317.

Donnelly JP, Blijlevens NMA and De Pauw BE (2010) Infections in the immunocompromised host: general principles. In: Mandell GL, Bennett JE and Dolin L (eds) Principles and Practice of Infectious Diseases, pp. 3781–3793. New York: Elsevier Churchill Livingstone.

El‐Maallem H and Fletcher J (1981) Effects of surgery on neutrophil granulocyte function. Infection and Immunity 32: 38–41.

Fishman JA (2007) Infection in solid‐organ transplant recipients. New England Journal of Medicine 357 (25): 2601–2614.

Gaynes R, Edwards JR and The National Nosocomial Infections Surveillance System (2005) Overview of nosocomial infections caused by Gram‐negative bacilli. Clinical Infectious Diseases 41: 848–854.

Geretti AM (2008) BHIVA guidelines: Immunisations. HIV Medicine 9: 795–848.

Giebel S, Maccario R, Lilleri D, et al. (2005) The immunosuppressive effect of human cytomegalovirus infection in recipients of allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplantation 36: 503–509.

Hot A, Schmulewitz L, Viard JP and Lortholary O (2007) Fever of unknown origin in HIV/AIDS patients. Infectious Disease Clinics of North America 21 (4): 1013–1032.

Humphreys H (2004) Positive‐pressure isolation and the prevention of invasive aspergillosis. Journal of Hospital Infection 56 (2): 93–100.

Katona P and Katona‐Apte J (2008) The interaction between nutrition and infection. Clinical Infectious Diseases 46: 1582–1588.

Klastersky J (2004) Management of fever in neutropenic patients with different risks of complications. Clinical Infectious Diseases 39: S32–S37.

Kourbeti IS, Ziakas PD and Mylonakis E (2014) Biologic therapies in rheumatoid arthritis and risk of opportunistic infections: a meta‐analysis. Clinical Infectious Diseases 58: 1649–1657.

Maertens J, Deeren D, Dierickx D and Theunissen K (2006) Preemptive antifungal therapy: still a way to go. Current Opinion in Infectious Diseases 19: 551–556.

Marr KA (2004) Stem cell transplant patients. In: Cohen J and Powderly W (eds) Infectious Diseases, pp. 1093–1098. London, UK: Mosby.

Novosad SA and Winthrop KL (2014) Beyond tumour necrosis factor inhibition: the expanding pipeline of biologic therapies for inflammatory diseases and their associated infectious sequelae. Clinical Infectious Diseases 58: 1587–1598.

Onishi A, Sugiyama D, Kogata Y, et al. (2012) Diagnostic accuracy of serum 1,3‐β‐D‐glucan for pneumocystis jiroveci pneumonia, invasive candidiasis, and invasive aspergillosis: systematic review and meta‐analysis. Journal of Clinical Microbiology 50: 7–15.

Peleg AY, Weerarathna T, McCarthy JS and Davis TME (2007) Common infections in diabetes: pathogenesis, management and relationship to glycaemic control. Diabetes/Metabolism Research and Reviews 23: 3–13.

Rubin LG and Schaffner W (2014) Care of the asplenic patient. New England Journal of Medicine 371: 349–356.

Scholl R, Bekker A and Babu R (2012) Neuroendocrine and Immune Responses to Surgery. The Internet Journal of Anesthesiology. 30 (3).

Smieja M, Marchetti C, Cook D and Smaill FM (1999) Isoniazid for preventing tuberculosis in non‐HIV infected persons. Cochrane Database of Systematic Reviews (1. Art. No.: CD001363). DOI: 10.1002/14651858.CD001363.

Spellberg B, Walsh TJ, Kontoyiannis DP, et al. (2009) Recent advances in the Management of Mucormycosis: from bench to bedside. Clinical Infectious Diseases 48: 1743–1751.

Tolkoff‐Rubin NE and Rubin RH (2004) Infection in solid organ transplantation. In: Cohen J and Powderly W (eds) Infectious Diseases, pp. 1099–1106. London, UK: Mosby.

Torres‐Madriz G and Boucher HW (2008) Perspectives in the treatment and prophylaxis of cytomegalovirus disease in solid‐organ transplant recipients. Clinical Infectious Diseases 47: 702–711.

Viscoli C and Castagnola E (2010) Prophylaxis and empirical therapy for infection in cancer patients. In: Mandell GL, Bennett JE and Dolin L (eds) Principles and Practice of Infectious Diseases, pp. 3793–3809. New York: Elsevier Churchill Livingstone.

Wallis RS, Broder MS, Wong JY, Hanson ME and Beenhouwer DO (2004) Granulomatous infectious diseases associated with tumour necrosis factor antagonists. Clinical Infectious Diseases 38: 1261–1265.

Walsh TJ, Teppler H, Donowitz GR, et al. (2004) Caspofungin versus liposomal amphotericin B for empirical antifungal therapy in patients with persistent fever and neutropenia. New England Journal of Medicine 351: 1391–1402.

Wyke RJ (1989) Bacterial infections complicating liver disease. Baillière's Clinical Gastroenterology 3 (1): 187–210.

Further Reading

Collier L, Balows A and Sussman M (eds) (2007) Topley and Wilson's Microbiology and Microbial Infections. London, UK: Arnold.

Rubin RH and Young LS (2002) Clinical Approach to Infection in the Compromised Host, 4th edn. New York: Kluwer Academic/Plenum Publishers.

Contact Editor close
Submit a note to the editor about this article by filling in the form below.

* Required Field

How to Cite close
Elliott, Ivo, and Venkatesan, Pradhib(Feb 2015) Infections in the Secondary Immunocompromised Host. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0002224.pub3]