Infectious complications and preventive strategies with the use of AZA, MMF, cyclosporine, and CP
| Drug . | Associated infection . | Preventive strategy . |
|---|---|---|
| AZA/MMF | Recognized association: • Virus: JC virus, cytomegalovirus, VZV Reported cases: • Bacteria: Listeria, Mycobacterium spp. • Viral: BK virus • Fungi: Cryptococcus, Aspergillus, PJP • Parasite: Toxoplasma | Clinical evaluation: • In patients managed with antimetabolites and presenting with new-onset neurological symptoms such as hemiparesis, apathy, confusion, cognitive deficiencies, ataxia, blurry vision or loss of vision, severe otalgia or hearing loss, need evaluation for a neurotropic infection (eg, PML, HZ reactivation, toxoplasmosis, Cryptococcus). • Brain imaging and neurology consultation are recommended in those with neurologic symptoms. Immunization: • HZ immunization is recommended and as stated in Table 2. |
| Cyclosporine | Recognized association: • Virus: cytomegalovirus in transplanted patients Reported cases: • Bacteria: Gram-negative sepsis • Virus: Herpes simplex, VZV | • No evidence outside of the transplant setting exists on the use of preventive strategies to minimize opportunistic infections. |
| CP | Recognized association: • Infections associated with neutropenia (common bacterial infection) Reported cases: • Bacterial: TB • Fungal: PJP, Aspergillus • Parasitic: SS | Laboratory testing: • Routine blood cell counts. Therapy should not be administered to patients with an absolute neutrophil count ≤ 1500/μL and/or platelets < 50 000/μL. Antimicrobial prophylaxis: • Antimicrobial prophylaxis against bacterial, fungal, or viral infection might be considered in certain cases of neutropenia and at the discretion of the managing physician. • In case of neutropenic fever, antibiotic therapy is indicated, as well as consideration for growth factors, especially in patients considered to be at increased risk for neutropenia complications (eg, elderly patients). • PJP prophylaxis in patients treated with combination CP and moderate-dose corticosteroids (ie, ≥15 mg to <30 mg PEQ daily). PJP prophylaxis can be discontinued once PEQ ≤ 5 mg daily. |
| Drug . | Associated infection . | Preventive strategy . |
|---|---|---|
| AZA/MMF | Recognized association: • Virus: JC virus, cytomegalovirus, VZV Reported cases: • Bacteria: Listeria, Mycobacterium spp. • Viral: BK virus • Fungi: Cryptococcus, Aspergillus, PJP • Parasite: Toxoplasma | Clinical evaluation: • In patients managed with antimetabolites and presenting with new-onset neurological symptoms such as hemiparesis, apathy, confusion, cognitive deficiencies, ataxia, blurry vision or loss of vision, severe otalgia or hearing loss, need evaluation for a neurotropic infection (eg, PML, HZ reactivation, toxoplasmosis, Cryptococcus). • Brain imaging and neurology consultation are recommended in those with neurologic symptoms. Immunization: • HZ immunization is recommended and as stated in Table 2. |
| Cyclosporine | Recognized association: • Virus: cytomegalovirus in transplanted patients Reported cases: • Bacteria: Gram-negative sepsis • Virus: Herpes simplex, VZV | • No evidence outside of the transplant setting exists on the use of preventive strategies to minimize opportunistic infections. |
| CP | Recognized association: • Infections associated with neutropenia (common bacterial infection) Reported cases: • Bacterial: TB • Fungal: PJP, Aspergillus • Parasitic: SS | Laboratory testing: • Routine blood cell counts. Therapy should not be administered to patients with an absolute neutrophil count ≤ 1500/μL and/or platelets < 50 000/μL. Antimicrobial prophylaxis: • Antimicrobial prophylaxis against bacterial, fungal, or viral infection might be considered in certain cases of neutropenia and at the discretion of the managing physician. • In case of neutropenic fever, antibiotic therapy is indicated, as well as consideration for growth factors, especially in patients considered to be at increased risk for neutropenia complications (eg, elderly patients). • PJP prophylaxis in patients treated with combination CP and moderate-dose corticosteroids (ie, ≥15 mg to <30 mg PEQ daily). PJP prophylaxis can be discontinued once PEQ ≤ 5 mg daily. |
Data are from Gibson et al,47 Prometheus Laboratories Inc.,48 Roche Laboratories Inc.,49 Kim and Perfect,50 and Baxter.51
PML, progressive multifocal leukoencephalopathy.