Fortnightly Review: The pneumococcal problem

Obaro, Stephen K.; Monteil, Michèle; Henderson, D. C.

doi:10.1136/bmj.312.7045.1521

Cited by 93 publications

(53 citation statements)

References 34 publications

(30 reference statements)

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“…Although several factors may contribute to immune response failure after sibling transplant 17,18 the spleen seems to be a key element in host defence against encapsulated bacteria; 11 post-BMT functional hyposplenism, attributed to the TBI regimen, has already been documented. 19 In this study we used ultrasound (US) scan to evaluate spleen size in bone marrow transplant patients and correlated spleen size with the occurrence of cGVHD and of EBI.…”

mentioning

confidence: 99%

“…3,7 However, the emergence of penicillin-resistant pneumococcal infections is a wordwide problem 8,9 occurring in both immunocompetent 10,11 and immunocompromised 12 patients. Since prolonged treatment with oral B-lactams may favor antibiotic resistance [13][14][15] and may produce side-effects such as diarrhea, colitis and pseudo-membranous colitis, 16 prudent and proper use of oral penicillin is suggested.…”

mentioning

confidence: 99%

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Spleen sizing by ultrasound scan and risk of pneumococcal infection in patients with chronic GVHD: preliminary observations

Picardi

Selleri

Rotoli

1999

Bone Marrow Transplant

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Summary:Encapsulated bacteria infections (EBI) can cause severe complications after BMT, usually occurring in patients with chronic GVHD (cGVHD) and attributed to functional hyposplenism. Using ultrasound (US) scan, we measured spleen size in 22 patients transplanted from HLA identical siblings, with or without cGVHD. No patient had received TBI, spleen irradiation or penicillin prophylaxis. Results were correlated with occurrence of EBI during a mean follow-up of 55 months (range 7-93). In the group without cGVHD, the difference between pre-and post-BMT spleen longitudinal diameters was not significant, and no patient developed EBI. In the cGVHD group, post-BMT spleen longitudinal diameters were significantly smaller than those pre-BMT (9.1 ± 1.6 vs 12.3 ± 2.2; P = 0.0005). Out of four patients with cGVHD who showed a major spleen size reduction, two developed a severe infection (an overwhelming sepsis and a pneumococcal meningitis). In our small series, we found a borderline relationship between spleen size reduction and duration of cGVHD (P = 0.06), as well as an increased risk of life-threatening infection in patients with extensive cGVHD and hyposplenism as detected by US scan. We conclude that US scan may be useful to detect spleen size reduction following allogeneic BMT and that penicillin prophylaxis is to be strongly recommended in patients with extensive cGVHD and spleen size reduction, even in those who have not received total body or spleen irradiation.

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mentioning

confidence: 99%

mentioning

confidence: 99%

Spleen sizing by ultrasound scan and risk of pneumococcal infection in patients with chronic GVHD: preliminary observations

Picardi

Selleri

Rotoli

1999

Bone Marrow Transplant

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“…Measurement of functional pneumococcal antibodies may help to identify non-responders who may require treatment with immunoglobulin. 20 Although splenic autotransplantation may facilitate an adequate immune response in patients who are splenectomised as a result of trauma, 21 this is clearly not an option in our patient.…”

Section: Discussionmentioning

confidence: 80%

Recurrent penicillin-resistant pneumococcal sepsis after matched unrelated donor (MUD) transplantation for refractory T cell lymphoma

Tauro¹,

Dobie²,

Richardson

et al. 2000

Bone Marrow Transplant

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Summary:Patients who undergo splenectomy and recipients of allogeneic marrow (alloBMT) or peripheral stem cell transplantation are at increased risk of overwhelming infection from encapsulated organisms such as Streptococcus pneumoniae, Haemophilus influenzae and Neiserria meningitidis. As prophylaxis against these pathogens splenectomised patients are immunised and may also receive antibiotics for life. We report relapsing overwhelming sepsis caused by penicillin-resistant pneumococcus in a patient who was immunised and received prophylactic phenoxymethylpenicillin for 8 months following splenectomy and matched unrelated donor (MUD) marrow transplantation for refractory T cell lymphoma. No obvious focus of sepsis was found during any of the three episodes and S. pneumoniae serogroup 6, subtype 6B was isolated from blood cultures on each occasion. He was treated with i.v. cephalosporins, as the organisms were resistant to penicillin with a minimum inhibitory concentration (MIC) of 2.0, and there was complete resolution of symptoms each time. In the light of recurrent sepsis with this penicillin-resistant organism the decision was made to give prophylactic levofloxacin for the next 12 months. This case illustrates that the choice of prophylactic regimen and the treatment of sepsis in immunocompromised patients remain difficult and challenging issues. 5 They are also immunised with 23-valent polysaccharide pneumococcal vaccine but the ability to generate an adequate antigen-specific immune response in recipients of alloBMT is time-dependent and may not be consistent. 6,7 To highlight the challenges in the primary prevention of sepsis with encapsulated bacteria in this group of patients, we report on the recurrence of serious penicillin-resistant pneumococcal sepsis in a patient, 8 months post-MUD transplantation for refractory T cell lymphoma. Case reportA 27-year-old man presented with splenomegaly and pancytopenia. A diagnosis of T cell NHL was made on trephine biopsy. He was treated with nine courses of CHOP chemotherapy. A splenectomy was performed 5 months after the initial diagnosis and nodular collections of small lymphocytic cells with slightly irregular nuclei and low mitotic rate, were detected on splenic sections. The cells expressed CD3, CD5 and CD43, thus confirming a diagnosis of lowgrade peripheral T cell lymphoma. Prior to the splenectomy he was immunised with 23-polyvalent polysaccharide pneumococcal vaccine, H. influenza type b (Hib) conjugate vaccine and meningococcal type A and C polysaccharide vaccine. He was subsequently treated with more chemotherapy (miniBEAM and subsequently a combination of idarubicin and cytosine arabinoside). However, marrow examination after completing chemotherapy continued to show infiltration with lymphoma, indicating refractory disease.Since the patient's sister was not HLA compatible, matched unrelated donor transplantation was performed 17 months after the initial diagnosis. The pretransplant conditioning regimen consisted of fractionated total body irradiation 1...

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“…El coste de tratar un número creciente de pacientes con enfermedad invasiva por cepas resistentes puede afectar de forma importante los recursos económicos de los servicios de salud, particularmente en aquellas comunidades donde exista un número importante de pacientes con alto riesgo de contraer enfermedad neumocócica 1 . Datos declarados en España en el año 1996 señalan una incidencia de neumonía de 420/100.000 habitantes y año; siendo la tasa de mortalidad global por neumonías de 17 por 100.000 habitantes.…”

unclassified

“…¿Cuáles serían los factores de riesgo asociados a infección neumocócica? : la edad, factores inmunológicos y otros factores precipitantes (Tabla I) 1 .…”

unclassified

El dilema sobre el coste-efectividad de la vacuna antineumocócica sigue abierto

Álvarez

Mayer

2001

Medifam

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Fortnightly Review: The pneumococcal problem

Cited by 93 publications

References 34 publications

Spleen sizing by ultrasound scan and risk of pneumococcal infection in patients with chronic GVHD: preliminary observations

Spleen sizing by ultrasound scan and risk of pneumococcal infection in patients with chronic GVHD: preliminary observations

Recurrent penicillin-resistant pneumococcal sepsis after matched unrelated donor (MUD) transplantation for refractory T cell lymphoma

El dilema sobre el coste-efectividad de la vacuna antineumocócica sigue abierto

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