Prevention of infectious complications and management of cytopenias resulting from CAR T-cell and bispecific T-cell recruiting antibodies
| Intervention category . | Intervention description . | Indications . | Notes . |
|---|---|---|---|
| 1. Antimicrobial Prophylaxis | |||
| All patients | |||
| Antiviral | Acyclovir or valacyclovir: prevention of HSV and VZV reactivation | All patients • CAR T-cell therapy: 12-18 months after infusion, at least until CD4 count >200/µL • Bispecific antibodies: during treatment and until 1 month after treatment discontinuation | |
| Pneumocystis jirovecii | Trimethoprim-sulfamethoxazole | All patients • CAR T-cell therapy: 12-18 months after infusion, at least until CD4 count >200/µL • Bispecific antibodies: during treatment and until 1 month after treatment discontinuation | Alternatives: dapsone, atovaquone, pentamidine (disadvantages include lack of activity against encapsulated organisms) |
| Selected patients | |||
| Antiviral | Entecavir | Prevention of HBV reactivation in patients with history of HBV infection or known exposure | |
| Antibacterial | Levofloxacin | Consider during periods of prolonged severe neutropenia (ANC <0.5 × 109/L) | |
| Antifungal | Fluconazole or posaconazole | During periods of severe prolonged neutropenia (ANC <0.5 × 109/L) or prolonged steroid therapy | |
| 2. Growth factors | G-CSF Thrombopoietin-receptor agonist | • Consider G-CSF if ANC <1.0 × 109/L; strongly recommend for ANC <0.5 × 109/L, especially if prolonged • Give G-CSF for active neutropenic infection • Consider TPO agonist if prolonged severe thrombocytopenia that persists beyond 30 days with high transfusion needs | • Caution in patients with active or high risk of CRS |
| 3. Immunoglobulin replacement | IVIG 400-500 mg/kg | Serum IgG ≤400 mg/dL | Monitor serum IgG levels every 4 weeks |
| 4. Vaccinations | Influenza COVID-19 | Influenza vaccine repeated annually COVID-19 vaccine series repeated ≥3 months after CAR T-cell therapy If feasible, patients should be vaccinated prior to therapy. | Consider measuring serum pathogen-specific IgG titers after vaccination to evaluate for seroprotection. There are limited data to comment on repeating routine immunizations following CAR-T therapy and bispecific antibodies. |
| Intervention category . | Intervention description . | Indications . | Notes . |
|---|---|---|---|
| 1. Antimicrobial Prophylaxis | |||
| All patients | |||
| Antiviral | Acyclovir or valacyclovir: prevention of HSV and VZV reactivation | All patients • CAR T-cell therapy: 12-18 months after infusion, at least until CD4 count >200/µL • Bispecific antibodies: during treatment and until 1 month after treatment discontinuation | |
| Pneumocystis jirovecii | Trimethoprim-sulfamethoxazole | All patients • CAR T-cell therapy: 12-18 months after infusion, at least until CD4 count >200/µL • Bispecific antibodies: during treatment and until 1 month after treatment discontinuation | Alternatives: dapsone, atovaquone, pentamidine (disadvantages include lack of activity against encapsulated organisms) |
| Selected patients | |||
| Antiviral | Entecavir | Prevention of HBV reactivation in patients with history of HBV infection or known exposure | |
| Antibacterial | Levofloxacin | Consider during periods of prolonged severe neutropenia (ANC <0.5 × 109/L) | |
| Antifungal | Fluconazole or posaconazole | During periods of severe prolonged neutropenia (ANC <0.5 × 109/L) or prolonged steroid therapy | |
| 2. Growth factors | G-CSF Thrombopoietin-receptor agonist | • Consider G-CSF if ANC <1.0 × 109/L; strongly recommend for ANC <0.5 × 109/L, especially if prolonged • Give G-CSF for active neutropenic infection • Consider TPO agonist if prolonged severe thrombocytopenia that persists beyond 30 days with high transfusion needs | • Caution in patients with active or high risk of CRS |
| 3. Immunoglobulin replacement | IVIG 400-500 mg/kg | Serum IgG ≤400 mg/dL | Monitor serum IgG levels every 4 weeks |
| 4. Vaccinations | Influenza COVID-19 | Influenza vaccine repeated annually COVID-19 vaccine series repeated ≥3 months after CAR T-cell therapy If feasible, patients should be vaccinated prior to therapy. | Consider measuring serum pathogen-specific IgG titers after vaccination to evaluate for seroprotection. There are limited data to comment on repeating routine immunizations following CAR-T therapy and bispecific antibodies. |
HBV, hepatitis B virus; HSV, herpes simplex virus; VZV, varicella zoster virus.