Haematopoietic stem cell transplant patients

PJP prophylaxis is indicated in all patients.

Start prophylaxis after the transplant when the patient is stable and tolerating oral medications. For antimicrobial regimens, see here. PJP prophylaxis with trimethoprim+sulfamethoxazole also provides prophylaxis against Toxoplasma gondii.

Duration of PJP prophylaxis:

The optimal duration of PJP prophylaxis is uncertain. Assess the patient’s level of immune compromise and risk of infection before stopping PJP prophylaxis. Review the benefit of ongoing prophylaxis regularly.

Continue PJP prophylaxis for 12 months after transplant or after stopping immunosuppressive therapy, whichever is later.

T. gondii prophylaxis is indicated for patients who are T. gondii IgG positive. T. gondii prophylaxis is not required if the patient is receiving trimethoprim+sulfamethoxazole for PJP prophylaxis. If the patient is hypersensitive to trimethoprim+sulfamethoxazole and requires prophylaxis for both PJP and T. gondii, see here for regimens.

Start prophylaxis after the transplant when the patient is stable and tolerating oral medications.

Duration of T. gondii prophylaxis:

Limited data are available to guide duration of T. gondii prophylaxis—seek expert advice. If the patient is taking trimethoprim+sulfamethoxazole for both PJP and T. gondii prophylaxis, use the duration of PJP prophylaxis as a guide.

Indications for CMV prophylaxis are beyond the scope of these guidelines—refer to local protocols. The choice between universal prophylaxis and pre-emptive treatment depends on several factors, including the availability of CMV monitoring, and the risk of CMV reactivation.

For universal prophylaxis, start from engraftment. For antiviral regimens, see Universal prophylaxis.

For pre-emptive treatment, start when indicated based on viral load or the rate of change in viral load. For antiviral regimens, see Pre-emptive treatmenty.

Duration of CMV prophylaxis:

Assess the patient’s level of immune compromise and risk of infection before stopping CMV prophylaxis.

For universal prophylaxis, continue until day 100 after transplant, or until day 180 if the patient has an episode of CMV disease before day 100, significant graft-versus-host disease (GVHD), or is taking corticosteroids or other ongoing immunosuppression at day 100.

For pre-emptive treatment, continue until one or two CMV DNA nucleic acid amplification (eg polymerase chain reaction [PCR]) test results are negative—consult local protocols.

HSV prophylaxis is indicated for patients who are HSV IgG positive. HSV prophylaxis is not required if the patient is receiving valganciclovir or ganciclovir for CMV prophylaxis.

Start HSV prophylaxis on the day before stem cell infusion. For antiviral regimens, see here.

Duration of HSV prophylaxis:

Continue HSV prophylaxis until engraftment, or longer if there is significant ongoing immunosuppression. If the patient is varicella-zoster virus (VZV) IgG positive, ongoing prophylaxis is required (see below).

Suppressive therapy:

If the patient has recurrent oral mucocutaneous or genital HSV infection, suppressive therapy is recommended. See Recurrent oral mucocutaneous herpes and Suppressive therapy for genital herpes.

VZV prophylaxis is indicated for patients who are VZV IgG positive. VZV prophylaxis is not required if the patient is receiving valganciclovir or ganciclovir for CMV prophylaxis.

Start VZV prophylaxis at engraftment. For antiviral regimens, see here.

Duration of VZV prophylaxis:

Continue VZV prophylaxis until 1 year after transplant, or longer if there is significant ongoing immunosuppression.

Antifungal prophylaxis against mould infection is recommended for high-risk patients such as patients with pre-engraftment neutropenia expected to last for more than 14 days, patients with previous infection or colonisation with Aspergillus species or other moulds, and patients with GVHD or other complications postengraftment requiring treatment with corticosteroids. Refer to local protocols.

Start antifungal prophylaxis on the day of stem cell infusion (if indicated pre-engraftment) or at onset of GVHD. For antifungal regimens, see here.

Duration of antifungal prophylaxis:

Refer to local protocols for duration of antifungal prophylaxis. Most centres continue prophylaxis for at least 75 days, or until the daily prednisolone dose is less than 15 mg, whichever is later. A longer duration of prophylaxis may be needed for patients with GVHD—seek expert advice and consult local protocols.

Antifungal prophylaxis against yeast infection is indicated for patients with neutropenia expected to last less than 14 days; however, yeast prophylaxis is not required if the patient is receiving mould prophylaxis.

Start prophylaxis on the day of stem cell infusion (if indicated pre-engraftment). For antifungal regimens, see here.

Duration of antifungal prophylaxis:

Refer to local protocols for duration of antifungal prophylaxis. Most centres continue prophylaxis for at least 75 days or until corticosteroids are stopped, whichever is later.

Antibiotic prophylaxis against S. pneumoniae is indicated for patients with GVHD, patients with hypogammaglobulinaemia and patients who develop bronchiolitis obliterans.

For antibiotic regimens, see here.

Duration of antibiotic prophylaxis:

Refer to local protocols for duration of S. pneumoniae prophylaxis. Recommendations vary; at a minimum, continue prophylaxis for the duration of immunosuppressive treatment. Some units continue for longer (eg 2 years).

Perform baseline Strongyloides serology in patients with a past or present epidemiological risk of acquiring S. stercoralis [NB2].

S. stercoralis prophylaxis (or pre-emptive treatment) is recommended for:

• patients with positive Strongyloides serology
• patients with negative serology who live in or visit an area in which S. stercoralis infection is endemic.

For antimicrobial regimens and duration of therapy, see here.

Perform baseline B. pseudomallei serology in patients who live or have lived in an endemic region such as tropical regions of Australia [NB3].

B. pseudomallei prophylaxis is recommended for:

• patients with positive B. pseudomallei serology
• patients with a history of melioidosis (B. pseudomallei infection) but no clinical evidence of current disease.

Consider giving primary prophylaxis during the wet season [NB4] to patients with negative B. pseudomallei serology who live in or visit an endemic area.

For antimicrobial regimens and duration of therapy, see here.

Hepatitis B virus and tuberculosis reactivation can occur, including in patients who are hepatitis B surface antigen (HBsAg) negative but who have antibodies to hepatitis B core antigen (anti-HBc). See Hepatitis B virus prophylaxis and Prevention of tuberculosis.

The risk of Listeria monocytogenes meningitis is increased. Consult local protocols and consider dietary and food safety measures to prevent L. monocytogenes infection [NB5].

Primary antiviral influenza prophylaxis may be indicated for hospitalised patients during institutional outbreaks. See Influenza virus prophylaxis.

PJP prophylaxis is indicated for patients with haematological malignancy.

Start prophylaxis after the transplant when the patient is stable and tolerating oral medications. For antimicrobial regimens, see here.

Duration of PJP prophylaxis:

The optimal duration of PJP prophylaxis is uncertain. Assess the patient’s level of immune compromise and risk of infection before stopping PJP prophylaxis. Review the benefit of ongoing prophylaxis regularly.

Continue PJP prophylaxis for 3 to 6 months after transplant or after stopping immunosuppressive therapy, whichever is later.

CMV prophylaxis or screening is not routinely indicated—refer to local protocols. CMV testing should only be performed if there is clinical suspicion of CMV disease.

HSV prophylaxis is indicated for patients with neutropenia who are HSV IgG positive.

Start prophylaxis on the day before stem cell infusion. For antiviral regimens, see here.

Duration of HSV prophylaxis:

Continue HSV prophylaxis until engraftment or day 30, whichever is shorter. If the patient is varicella-zoster virus (VZV) IgG positive, ongoing prophylaxis is required (see below).

Suppressive therapy:

If the patient has recurrent oral mucocutaneous or genital HSV infection, suppressive therapy is recommended. See Recurrent oral mucocutaneous herpes  and Suppressive therapy for genital herpes.

VZV prophylaxis is indicated for patients who are VZV IgG positive.

Start VZV prophylaxis at engraftment. For antiviral regimens, see here.

Duration of VZV prophylaxis:

Continue VZV prophylaxis for 12 months after transplant, or longer if there is significant ongoing immunosuppression.

Antifungal prophylaxis against mould infection is not routinely indicated. Use prophylaxis for patients with a history of invasive aspergillosis (or other mould infection), or patients who have been treated with extensive chemotherapy (particularly fludarabine) for refractory malignancy. Seek expert advice or consult local protocols.

Antifungal prophylaxis against yeast infection is indicated for patients who have been treated with extensive chemotherapy (particularly fludarabine) for refractory malignancy, those treated with a conditioning chemotherapy regimen associated with a greater risk of mucositis, or if prolonged neutropenia is anticipated.

Start antifungal prophylaxis on the day of stem cell infusion. For antifungal regimens, see here.

Duration of antifungal prophylaxis:

Continue antifungal prophylaxis until the neutrophil count recovers (more than 0.5 × 10⁹/L).

Perform baseline Strongyloides serology in patients with a past or present epidemiological risk of acquiring S. stercoralis [NB2].

S. stercoralis prophylaxis (or pre-emptive treatment) is recommended for:

• patients with positive Strongyloides serology
• patients with negative serology who live in or visit an area in which S. stercoralis infection is endemic.

For antimicrobial regimens and duration of therapy, see here.

Perform baseline B. pseudomallei serology in patients who live or have lived in an endemic region such as tropical regions of Australia [NB3].

B. pseudomallei prophylaxis is recommended for:

• patients with positive B. pseudomallei serology
• patients with a history of melioidosis (B. pseudomallei infection) but no clinical evidence of current disease.

Consider giving primary prophylaxis during the wet season [NB4] to patients with negative B. pseudomallei serology who live in or visit an endemic area.

For antimicrobial regimens and duration of therapy, see here.

Hepatitis B virus and tuberculosis reactivation can occur—some patients require antimicrobial treatment. For details, see Hepatitis B virus prophylaxis and Prevention of tuberculosis.

The risk of Listeria monocytogenes meningitis is increased. Consult local protocols and consider dietary and food safety measures to prevent L. monocytogenes infection [NB5].

Primary antiviral influenza prophylaxis may be indicated for hospitalised patients during institutional outbreaks—see Influenza virus prophylaxis.