Managing ill pt on immunosuppressant

[SCPA]

What considerations or changes do you make in workup and treatment of an acutely ill patient currently on an immunosuppressant drug? 

Intentionally vague question to hopefully provoke discussion. Would love to hear about general strategies and specific cases alike. 

[jk5142]

1. consider/cover for possible opportunistic infections (to include viral, fungal organisms)

 

2. drug levels/monitoring

-consider drug toxicity

-if continuing current IS regimen, probably consult whoever is managing tx

 

3. close monitoring of renal function 

 

[lkth487]

Agree with above. 

 

For peds:

• Fever and Neutropenia a big consideration, for those undergoing chemo.  Avoid NSAIDs especially.  Broad coverage.
• Rashes are not necessarily benign
• You can generally never trust a white count in pediatrics but especially not in an immunocompromised patient - they can't mount a response as well

[thinkertdm]

Immunocompromised can still develop antibiotic resistance, so think before blindly giving an antibiotic for a viral infection.  I've had immunocompromised people smugly tell me about their cough for four days, and they need xyz.

Also, if they are immunocompromised, an urgent care or walk-in is the last place they should go.

[lkth487]

Absolutely.  With that said, it's difficult in a fever and neutropenic child.  The majority will inevitably be a viral infection - but you're kind of obligated to go down the cultures and antibiotic route.  Of course, those kids shouldn't be going to a UC - they should come to a children's hospital with an inpatient onc unit.  

[lkth487]

For example, an onc kid with a white count of zero has a fever to 39 with clear URI sx, you do a DFA and it's positive for a virus - that kid still needs admission with  ceftaz (or other abx with pseudomonal coverage).  If the ANC is above 500 (or some other institution dependent number), you may be able to just do cultures, give ceftriaxone and send them home with close follow up in pedi onc clinic. 

[thinkertdm]

Indeed...the only thing missing is to discuss with the parents what is going on, that walk ins and urgent cares are not for them; and most importantly, provide a way for them to get answers to their questions in a timely manner.  Many times parents haul their kids in because they don't realize they can see another provider, they can ask for a nurse or a sooner appointment.  Their follow up is six months away, or the robot told them when they called that the provider was "busy" and they panic.  But when no immune system exists, you need to give 'em one, a la antibiotics.