Pretransplant Evaluation

A careful pretransplant infectious disease history should be obtained in all HSCT candidates (Table 99.1). This should include a history of prior bacterial, mycobacterial, and opportunistic infections, especially invasive fungal infections produced by Aspergillus or Candida species. In those with prior invasive fungal disease, a careful clinical and radiographic evaluation should be performed to exclude residual active disease, which would require aggressive treatment prior to HSCT. Antimicrobial susceptibility profiles of recent bacterial pathogens should be noted, as patients may remain colonized with these organisms. Patients with a prior history of tuberculosis, exposure to tuberculosis, or positive skin test for tuberculosis should be evaluated clinically and with chest radiograph for evidence of active disease. A travel history should be obtained to identify potential exposure, even in the remote past, to Strongyloides stercoralis, which may reactivate in the face of immunosuppression. Patients with potential exposure or unexplained peripheral eosinophilia should be screened pretransplant for

Table 99.1 Components of a pre-HSCT infectious diseases evaluation

■ Complete infectious disease history, including prior infections, antimicrobial susceptibility profiles, and their management

■ In those with prior invasive fungal infection or nocardiosis, clinical evaluation and imaging studies to assess disease activity

■ Travel and immunization history

Selected screening for Strongyloides stercoralis and Trypanosoma cruzi in those at risk

■ Evaluation for TB exposure, clinical, and radiographic evaluation in those at-risk

■ Dental evaluation

■ Serologic testing for CMV, HSV, VZV, EBV, hepatitis A,B,C, HIV 1 and 2, Toxoplasma gondii, Treponema pallidum

S. stercoralis with an enzyme-linked immunosorbent assay, which has a sensitivity exceeding 90% in detecting latent asymptomatic infection. Seropositive individuals should receive ivermectin prior to HSCT. Individuals who were born or have resided in areas of South America, Central America, or Mexico where Chagas disease is endemic, or who have received a blood transfusion while visiting those areas, should be screened for Trypanosoma cruzi IgG using at least two serologic tests.2 Serologic testing should also be performed to identify prior exposure to cytomegalovirus (CMV), varicella zoster virus (VZV), herpes simplex virus (HSV), human immunodeficiency virus 1 and 2 (HIV), hepatitis A, B and C, Epstein—Barr Virus (EBV), Toxoplasma gondii, and Treponema pallidum. CMV-seronegative HSCT recipients are at-risk for acquiring CMV from seropositive donors or blood products. CMV-seronegative candidates for allogeneic HSCT with a CMV-seronegative donor should receive only CMV-seronegative or leukocyte-reduced red cells and platelets.2

A formal dental evaluation should be performed in all HSCT candidates and, if necessary, restorative work completed prior to transplant so as to minimize the occurrence of infection from oral mucositis associated with the conditioning regimen. This is especially important given the emergence of viridans streptococci as important pathogens in the early transplant period.6

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