John A. Molinari, Ph.D. John A. Molinari, Ph.D. Director of Infection Control Director of Infection Control THE DENTAL ADVISOR THE DENTAL ADVISOR Ann Arbor, Michigan Ann Arbor, Michigan INFECTIONS IN IMMUNE INFECTIONS IN IMMUNE COMPROMISED PATIENTS COMPROMISED PATIENTS
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John A. Molinari, Ph.D.John A. Molinari, Ph.D.
Director of Infection ControlDirector of Infection ControlTHE DENTAL ADVISORTHE DENTAL ADVISOR
Ann Arbor, MichiganAnn Arbor, Michigan
INFECTIONS IN IMMUNEINFECTIONS IN IMMUNECOMPROMISED PATIENTSCOMPROMISED PATIENTS
Major Immune SystemsMajor Immune SystemsRequired for Host DefensesRequired for Host Defenses
Immune Compromised PersonImmune Compromised Person
person with impairments in the body’s normal mechanisms of defense against infection.
individual with 1 or more defects in body’s normal defense mechanisms that predispose them to infections, often opportunistic and life-threatening, that would otherwise not occur.
increasing % of population.degree of immune deficiency can vary with time &
therapy.
Categories of Host Defects Associated with Categories of Host Defects Associated with Impaired ResistanceImpaired Resistance
1. defects in cutaneous barriers: (severe dermatological conditions)2. mucous membrane barrier defects: (mucositis; trauma, smoking)3. conditions that cause obstruction of a natural body passage:
(neoplasia; foreign bodies; cystic fibrosis) 4. abnormal number of functional granulocytes: (leukemia, anti-
Selective IgA Deficiency:- most common inherited specific Ab deficiency.- noted in 1 of 700 - 800 persons. - no obvious disease susceptibility.- occurs more commonly in people with chronic
lung disease.- diminished secretory immune protection.- more common than diagnosed ? - increased susceptibility to acute GI, respiratory,
- Malnutrition - Transplantation- Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes- Effects of aging - Alcoholic cirrhosis- Asplenia - Chronic hepatitis B or C- Trauma - Arthritis- Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease
(uremia & dialysis)
NeoplasiaNeoplasiaAcute Leukemia:- infection major cause of death.- mostly opportunistic infections.- gram-bacilli, fungi, herpesviruses.- severe decrease in mature functioning
granulocytes purulence in infections can be diminished or absent.
- neutrophils show impaired ability to migrate. - diminished bactericidal chemotaxis.
NeoplasiaNeoplasia
Chronic Lymphocytic Leukemia:- usually involves B - lymphocytes.- affects humoral (Ab) immune responses.- secondary hypogammaglobulinemia, with
- Malnutrition - Transplantation- Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes- Effects of aging - Alcoholic cirrhosis- Asplenia - Chronic hepatitis B or C- Trauma - Arthritis- Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease
(uremia & dialysis)
AntiAnti--Neoplastic TherapyNeoplastic Therapy
Representative General Adverse Effects:- bone marrow suppression- generalized edema- alopecia - cystitis - pulmonary fibrosis- bleeding tendencies (due to thrombocytopenia)- ulceration of mucosa tissues- allergic reactions to prolonged drug regimens
AntiAnti--Neoplastic TherapyNeoplastic Therapy
Representrative Maxillofacial / Intra-oral Adverse Effects:- allergic reactions to anti-neoplastic agents- intra-oral ulceration- gingival tissue edema - decreased tolerance of stress of dental visits
- Malnutrition - Transplantation- Neoplasia - Parenteral Drug Abuse- Anti-neoplastic therapy - Diabetes- Effects of aging - Alcoholic cirrhosis- Asplenia - Chronic hepatitis B or C- Trauma - Arthritis- Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease
(uremia & dialysis)
Immunosuppression In DiabetesImmunosuppression In Diabetes
Est. 7% US adults (8 million).Susceptible to many local & systemic infections.Certain infections tend to be more common.Impaired Innate Cellular Defenses:- PMN abnormalities - adherence, chemotaxis,
phagocytosis, intracellular microbial killing.- prolonged, less effective, pathogen response. - susceptible to metastatic acute infections.- abnormalities in maocytes / macrophages .
Immunosuppression In DiabetesImmunosuppression In Diabetes
Humoral Immunity:- normal Ab levels & vaccination responses.
Cellular Immunity:- decreased T- lymphocyte responses.- abnormal Type IV (delayed) hypersensitivity.
Infections In Diabetics Infections In Diabetics
Head & Neck Infections:Occurring Predominantly (>50%) in Diabetics:
- rhinocerebral mucormycosis - severe otitis externa (multiple causes)
ID Contributary Factors In Transplant Pts ID Contributary Factors In Transplant Pts
Transplant factors:- type of transplant (common infection site)- surgery trauma Immunosuppression:
- immunosuppressive drugs Allograft Reactions:
- graft-vs-host reaction (cofactor in CMV &fungal infection)
- host-vs-graft reaction ?
Common Microbial Etiologies PostCommon Microbial Etiologies Post--TransplantationTransplantation
Bacteria: common gm+ & gm- flora- local contaminant infections & can spread
Fungi: Candida sp.; Aspergillus sp.; Pneumocystis- superficial mycoses which can metastizize- Candida common in liver transplant pts- Aspergillosis airborne from environment
Viruses: Herpesviruses; Papillomaviruses- many donors latently infected
- Malnutrition - Transplantation- Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes- Effects of aging - Alcoholic cirrhosis- Asplenia - Chronic hepatitis B or C- Trauma - Arthritis- Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease
(uremia & dialysis)
Infectious Complications In Asplenic PtsInfectious Complications In Asplenic Pts
Critical role in immune surveillance & response.Asplenic pts: lower C3 levels & defective
responses to encapsulated bacterial pathogens- decreased phagocytosis & destruction of
microbes.- failure to recognize polysaccharide Ag’s.- impaired IgM synthesis early in infection.- failure to remove Ab - coated bacteria.- prone to post-splenectomy sepsis (PSS). - S. pneumoniae (#1), H influenzae (#2),
N. meningitidis (#3)
Streptococcus pneumoniae (#1):- etiology in 50 – 90% PSS cases. - age major factor - % cases increase with age.- high mortality rate in children.Haemophilus influenzae (#2):- 32% of PSS mortality.- decreased incidence with conjugated Hib
vaccine use (important to vaccinate pts!!). Neisseria meningitidis (#3):- greater risk for meningococcemia (?)
•• Deep aching or burning painDeep aching or burning pain•• Altered sensitivity to touch (paresthesia) Altered sensitivity to touch (paresthesia)
that may be painful (dysesthesia)that may be painful (dysesthesia)•• Exaggerated responses to stimuli Exaggerated responses to stimuli
(hyperesthesia)(hyperesthesia)•• Electric shockElectric shock--like painlike pain
Zoster in Immunocompromised PtsZoster in Immunocompromised Pts•• More severe than in normal personsMore severe than in normal persons•• Lesion formation may continue for up to 2 wks, Lesion formation may continue for up to 2 wks,
scabbing may not occur until 3scabbing may not occur until 3--4 weeks into the 4 weeks into the disease coursedisease course
•• Frequent infection in HIV ptsFrequent infection in HIV pts•• Chronic herpes zoster may occurChronic herpes zoster may occur
3 Types of Varicella – Containing Vaccines:Varicella vaccine (Varivax)– approved for persons 12 months and older
Measles-mumps-rubella-varicella vaccine (ProQuad)– approved for children 12 months through 12 years
Herpes zoster vaccine (Zostavax)– approved for persons 60 years and older
Vaccine Recommendations for Adolescents & Adults:All persons 13 years of age and older without
evidence of varicella immunity2 doses separated by at least 4 weeksDo not repeat 1st dose because of extended interval
between doses
Herpes Zoster Vaccine*Herpes Zoster Vaccine*
•• Approved for a single dose among persons Approved for a single dose among persons 60 years and older whether or not they 60 years and older whether or not they report a prior episode of shingles report a prior episode of shingles
•• Persons with a chronic medical condition Persons with a chronic medical condition may be vaccinated unless a may be vaccinated unless a contraindication or precaution exists contraindication or precaution exists for the conditionfor the condition
•• Major transmission modes:Major transmission modes:1.1. via infected /colonized patientsvia infected /colonized patients2.2. dissemination by infected/ colonized dissemination by infected/ colonized
HCWsHCWs•• Within a facility: Within a facility:
-- HCW hands after contact with infected pt.HCW hands after contact with infected pt.•• Between hospitals & institutions:Between hospitals & institutions:
-- pt transfers & new carrier HCW pt transfers & new carrier HCW employees.employees.
- Malnutrition - Transplantation- Neoplasia - Parenteral Drug Abuse- Anti-neoplastic therapy - Diabetes- Effects of aging - Alcoholic cirrhosis- Asplenia - Chronic hepatitis B or C- Trauma - Arthritis- Autoimmune conditions - HIV / AIDS
- Other chronic infections - End stage renal disease (uremia & dialysis)
Infections Related to Steroid UseInfections Related to Steroid Use
Dramatic increase in corticosteroid use c/in last decade.Anti-inflammatory &/or immunosuppressive.Chronic steroid use predisposes to variety of infections by interfering c host defenses.Affect most aspects of immune system.Infections dependent on route of administration, dose, & duration of therapy.Most common: oropharyngeal candidiasis.Most common: oropharyngeal candidiasis.Prolonged CMI suppression important for Prolonged CMI suppression important for opportunistic infection to occur. opportunistic infection to occur.
Klein, et al. IDCNA (2001)Klein, et al. IDCNA (2001)
Infections Related to Steroid UseInfections Related to Steroid Use
increased susceptibility to all types of infection.
most infections caused by pyogenic bacteria.
pts on chronic steroid use at increased risk of surgical wound infections & delayed wound healing:steroids interfere with fibroblast steroids interfere with fibroblast proliferation & collagen synthesis. proliferation & collagen synthesis.
Klein, et al. IDCNA (2001)Klein, et al. IDCNA (2001)
Misuse of Topical Corticosteroids Misuse of Topical Corticosteroids
can cause transient immune suppression in otherwise healthy persons
mainly act on CMI can interfere with macrophage phagocytosiscan interfere with macrophage phagocytosis
& antigen& antigen--processing during immune processing during immune responsesresponses
when mistakenly applied topically onto when mistakenly applied topically onto superficial infections superficial infections -- can inhibit host can inhibit host
immune responses to microbial pathogensimmune responses to microbial pathogensJAM (2009)JAM (2009)
Hepatitis C, G, etc Hepatitis C, G, etc Hepatitis C, G, etc S A R SS A R S