Most infections following transplant come from organisms within the body (e.g., cytomegalovirus, mouth and gut bacteria). Good hand washing by parents, visitors, and health care workers can help decrease the risks of infections from bacteria and fungi.
The immune systems of healthy children quickly destroy any foreign invaders; this is not so with children who have undergone a transplant. The immune systems of these children have been destroyed by chemotherapy and radiation to allow the healthy stem cells to grow. Until the new stem cells engraft and begin to produce large numbers of functioning white cells, children post-transplant are in danger of developing serious infections.
During conditioning and until recovery of neutrophil counts, children are at high risk for developing bacterial infections. Fungal infections can also occur. The use of growth factors (such as GCSF) that stimulate and accelerate white blood cell recovery has decreased the time it takes for neutrophil engraftment, thus decreasing the incidence of serious infections. Your child may receive this medication one to two days following the transplant procedure. Additionally, your child will be evaluated carefully each day for signs and symptoms of infection. Potential sites of problems include the skin, mouth, perirectal area, and central venous catheter exit site. Report to your nurses immediately any new symptoms such as cough, shortness of breath, abdominal pain, diarrhea, pain on urination, vaginal discharge, or mental confusion. Antibiotics will be started promptly for any signs of infection. Some centers will use preventive (prophylactic) antibiotics even without signs of infection.
Leah had so many problems with infections and getting her counts back up that she spent two years on steroids, cyclosporin, and monthly gammaglobulin.
During the related mismatched allogeneic transplant, I developed no mouth sores, no infections, no GVHD. Just a headache the whole time. I do miss being an athlete, I do miss the friends that I lost, and I do miss my blond hair. (It came back in brown, so I tried to dye it blond, and it turned bright, fluorescent red.) But I can deal with those things. To survive I think you need luck, a positive attitude, and a decorated room to help you stay cheery.
After the first month post-transplant, children are also susceptible to serious viral infections, most commonly herpes simplex virus, cytomegalovirus (CMV), and varicella zoster virus, particularly if they have GVHD. These infections can occur up to two years after the transplant. Viral infections are notoriously hard to treat, so many centers use prophylactic acyclovir, granciclovir, or immunoglobulin to prevent them. CMV is usually preventable if the patient and donor are both CMV-negative and all transfused blood products are CMV-negative or filtered to remove white blood cells.
Interstitial pneumonitis, a sometimes fatal form of pneumonia, is most common the second or third month post-transplant. It is uncommon after autologous transplants and is most often associated with GVHD after allogeneic transplants.
The most common organisms that cause infections are cytomegalovirus and pneu-mocystis carinii. The risk of the latter infection can be decreased by using preventive (prophylactic) trimethoprim/sulfamethoxazole once engraftment has occurred.
Immunity is not carried over well from the donor to the child. Therefore the patient has to redevelop an immune system. If there is no GVHD, this will require at least six to twelve months. If GVHD is present, the recovery period may require years. During immune recovery a child must redevelop immunity to the common organisms that infect all children. This will require the usual childhood immunizations. Live virus vaccines should be avoided, however, since the immune system after transplantation is very fragile and may not be able to handle a large viral load.
Preventing infections is the best policy for children who have had a bone marrow or stem cell transplant. The following are suggestions to minimize exposure to bacteria, viruses, and fungi:
• Medical staff and all family members must wash their hands before touching the child.
• Keep your child away from crowds and people with infections.
• Do not let your child receive live virus inoculations until the immune system has fully recovered; your oncologist will determine the appropriate date for reinitiating immunizations.
• Keep your child away from anyone who recently has been inoculated with a live virus (chicken pox, polio).
• Keep your child away from barnyard animals and all types of animal feces.
• Have all carpets shampooed before the child returns home from the transplant.
• Avoid home remodeling while your child is recovering.
• Call the doctor at the first sign of a fever or infection.
For more information on infections, get the September 1993 BMT Newsletter, "Infections," or read Chapter 8 of Bone Marrow Transplants: A Book of Basics for Patients, by Susan Stewart. These and other useful resources are listed in Appendix D.
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