Einheit für pädiatrische Infektiologie Das immunsupprimierte Kind im Alltag des Kinderarztes: Impfungen? Infektionen?
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1 Einheit für pädiatrische Infektiologie Das immunsupprimierte Kind im Alltag des Kinderarztes: Impfungen? Infektionen? Andrea Duppenthaler
2 what s the matter?
3 and what s not the matter? Fever in Neutropenia, chemotherapy induced Transplantation - Period Severely ill patients under immunosuppression referral to hospital
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7 what s the matter? identification patients at increased risk prevent infections in immunocompromized persons special needs of immunocompromized persons different/distinct clinical presentation under immunosuppression
8 Immunosupressive Drugs, what for? Indications: Transplantations Rheumatology Gastroenterology Neurology Haematology Oncology Dermatology Vasculitis/ systemic inflammation
9 Immunosuppression/ - modulation Steroids / ACTH Methotrexat Azathioprin Ciclosporin/Tacrolimus Everolimus/Sirolimus Antibodies (Rituximab, etc) Immunoglobulins..
10 Grouping according of way of action Glucocorticoids mtor (Everolimus, Sirolimus) Calcineurin Inhibitors (Ciclosporin, Tacrolimus) Antimetabolites (Mycophenolat, Azathioprine) Antibodies (XY.. -ab) Receptor blocker (XY..-cept)
11 Immunosuppression/ - modulation Steroids / ACTH Methotrexat Azathioprin Ciclosporin/Tacrolimus Everolimus/Sirolimus Antibodies (Rituximab, etc) Immunoglobulins..
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13 ? first/second Dose VZV? dosage MTX? duration of immunosuppression 2. dose 0.5mg/kg/week 5 months and now?
14 Risk evaluation: Exposition? relevant in: Household: residing in the same household Playmate: face to face indoor play (5Min?, 60Min?*) Hospital: same room, face to face to infectious visitor * consider decreasing infectiousness in disease course
15 Risk evaluation: Exposition? Degree of immunosuppression? Interval to exposition?
16 2. VZV MTX 0.5mg/kg/w 5 months VZV IgG? latency? Antivirals? Which drug? When? other? up to 10 days
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18 Antivirals for VZV: Aciclovir: licensed liquid formulation low bioavailability recommendation in immunosuppressed patients: only i.v. Valaciclovir: not licensed liquid formulation extemporaneously compounded good bioavailability no official recommendation pre-emptive treatment: day 8 15 post exposure
19 2. VZV MTX 0.5mg/kg/w 5 months no VZV - IgG no prae-emptive treatment on hold: antiviral treatment (Valaciclovir 20mg/kg q8h)) favorable course, no clinical signs
20 Infection Risk under Immunosuppression defined by: Disease Duration Dosage of immunosuppressive medication Co Medications (1+1 > 2) over all: higher risk under immunosuppression Risk stratification on individual basis
21 Infection andimmunosuppression Virus > Bacteria > opportunistic (Fungi/Parasites) Antibiotic treatment only if bacterial infection is evident no prophylactic treatment
22 Atypical presentation of infectious diseases or presentation of atypical diseases Risk of underestimation clinical signs and symptoms: Steroids Neutropenia Biologicals (Infliximab etc)
23 + 30 h + Lc 0.68 G/l
24 Diagnosis of infectious diseases prolonged viremia/bacteriemia (Blood culture, Viral - PCR) higher pathogen load humoral response +/- impaired (serology!) pathogen identification (culture (+ resistence testing), PCR) work up
25 Prophylaxis > treatment! Vaccinations: Routine immunization consider minimal ages Catch up, if needed shorten interval between 2 doses only minimal intervals to respect, no maximal Additional vaccines?
26 Vaccination in immunosuppressed patients No restriction for inactivated vaccines No risk of adverse events, but immunogenicity can be reduced! AB - response is more restricted after Primovaccination than after Booster doses: immunization before immunosuppression! Check AB response after Primovaccination in case of immunosuppression (6 weeks after)
27 BAG 2014 Februar
28 14 months old girl Dg.: JIA (Gonarthritis and Uveitis) start NSAR and corticosteroid eye drops What to do? Vaccination card: Hexa MMR PCV13 3 X X 5 X 6 X X 10 X 12 X
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30 BAG Bulletin 2014;; Nr. 8
31 14 months old girl Hexa MMR PCV13 VZV MenC YF? 3 X X 5 X 6 X X 10 X 12 X 14 X X 15 X X X
32 Live Vaccines 2 Doses: MMR VZV minimal interval between doses: 4 weeks 1 Dose: Yellow Fever, if travel in endemic region is feasible Immunization with live vaccines 4-6 weeks prior to start of immunosuppressive treatment minmal age to start: 9 (6) months
33 Prophylaxis > treatment! Vaccinations: Routine immunization consider minimal ages Catch up, if needed shorten interval between 2 doses only minimal intervals to respect, no maximal Additional vaccines? VZV, Yellow Fever, Flu, HBV/HAV, HPV
34 14 months old girl Dg.: JIA (Gonarthritis and Uveitis) upcoming systemic immunsuppressive treatment What to do? Vaccination card ü Family: siblings? VZV! seasonal Flu shot
35 Exposure Prophylaxis Flu BAG Impfempfehlung 2016
36 Influenza Prophylaxis: Immunization immunosuppressed persons, family members (grandparents) and health care workers Treatment: Neuraminidase Inhibitors: Oseltamivir, (Zanamivir) Ø 1 year, oral (Some) Efficacy when treatment starts within 24h of illness, much less, when later. Indication: in immunosuppressed and severe disease
37 Drug Drug Interaction! Immunosuppressives AND Makrolids TMP-SMX, Chinolone (MTX) Antifungals (Azole) NSAR PPI Nephrotoxicity of some immunsuppressive medication Dose adjustement?
38 Don t forget: High Dose IVIG (Kawasaki-Syndrome, Guillain-Barré Syndrome, ITP) postpone live vaccines: 6 (-9) months Transfusion: postpone live vaccines: 6 (-9) months
39 Biologicals in pregnancy
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42 Biologicals in pregnancy not enough safety data for use during pregnancy not to start with during pregnancy counseling individually Recommendations for live vaccines in offsprings: Cimzia : 12 weeks (no placenta passage) Remicade : 6 months
43 Summary increasing number of immunocompromised children/adolescents or children of immunocompromised family members Risk population for more severe infectious diseases Immunizations: as much as possible before immunosuppression shorten interval, respect minimal age (HPV) Nr. 1: live vaccines (MMRV YF) Nr. 2: additional shots (eg HBV, HAV, Flu) Nr. 3: no restriction for inactivated vaccines it s a family affair
44 Summary Patient/familiy education: VZV exposition, hygiene Unusual presentation of infectious diseases Microbiologic work up Treatment indications (Antivirals? IgG?) Drug Drug Interactions Define communication line and responsabilities with specialists
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