Diphtheria, Tetanus, and Acellular Pertussis
16.7.2 Pneumococcal Conjugate Vaccine
In areas without routine pneumococcal vaccina- tion, invasive pneumococcal disease remains a potential risk during and after chemotherapy Meisel et al. 2007 . Allen and Weiner 1981 reviewed 40 episodes of sepsis in 28 children with leukemia and lymphoma and found that 35 of these episodes were secondary to S. pneu- moniae , the most commonly isolated organism. Interestingly, S. pneumoniae was the only organ- ism that caused infection during remission ther- apy; fi ve of the 40 episodes 12.5 were during this time and due to S. pneumoniae . Lehrnbecher et al. 2009 studied 53 children treated for ALL and found persistent lack of protection to pneu- mococcal antigens which was signifi cantly lower than age-matched, unvaccinated, healthy controls up to 9 months after the completion of therapy the study period. Protection during chemotherapy from vaccine strains in those with previous immunization is unknown. Patel et al. 2012 studied 42 children with a history of leukemia ≥6 months off of che- motherapy to assess for serotype-specifi c antibod- ies to S. pneumoniae . None of the subjects were noted to have protective antibody concentrations to pneumococcal conjugate vaccine serotypes. Cheng et al. 2012 administered two doses of PCV7 to 44 pediatric oncology patients, including 20 ALL patients in maintenance. Eighty-six to 100 of patients obtained seropositivity depend- ing on the pneumococcal serotype. No subgroup analysis was reported to determine if differences in seropositivity occurred with different underly- ing malignancies or based on timing of vaccination. Beyond patients that have received splenectomy as part of their therapy, there is no indication for immunization with the 23-valent pneumococcal polysaccharide vaccine.16.7.3 Hemophilus Infl uenzae Type b
In settings with routine vaccination to Hib, inva- sive disease has plummeted Bisgard et al. 1998 . Risk still remains though in areas without routine immunization Siber 1980 ; Feldman et al. 1990 . Multiple studies have described the effect of Hib conjugate immunization during chemotherapy Feldman et al. 1990 ; Kaplan et al. 1992 ; Shenep et al. 1994 ; Cheng et al. 2012 . Feldman et al. 1990 vaccinated 50 children with Hib; the over- all response rate was 50 . Shenep et al. 1994 studied 50 children with solid tumors who had not previously been vaccinated for Hib. Seroresponse was noted in 42 after fi rst vacci- nation and another 45 responded to a second dose. Kaplan et al. 1992 studied 18 children with malignancy and found a 50 seroresponse rate to Hib after 1 immunization. One-third of children responded to a second dose. Weisman et al. 1987 studied 27 children with malignancy, 6 of whom had completed therapy to measure response to Hib vaccination. Eighty-fi ve percent of patients had an appropriate response. Solid tumor patients had a 100 response; there was no difference in response for those off therapy. Of note, all of these studies were done at a time of signifi cantly decreased chemotherapeutic inten- sity making it unclear as to their generalizability with modern therapeutic protocols.16.7.4 Inactivated Poliovirus
The risk of polio is negligible due to the near worldwide eradication of the virus. Only one rel- evant study by Ogra et al. 1971 could be found, comparing antibody response in patients with leukemia, solid tumors and healthy controls. Response in healthy controls and solid tumor patients was similar while those with leukemia had a blunted response. Again, due to the age of this study, the generalizability to modern thera- peutic protocols is unknown. Of note, oral polio- virus OPV is contraindicated.16.7.5 Infl uenza
16.7.5.1 Inactivated Infl uenza Vaccine Although in a Cochrane review Goossen et al.
2009 conclude that there is a paucity of well designed randomized controlled trials to defi ne whether infl uenza vaccination in children with malignancy during therapy is benefi cial consider- ing their blunted response to vaccination, no signifi cant adverse effects were seen in the stud- ies reviewed, and the general consensus is that the benefi t of vaccination outweighs cost and any other potential risks, even if seroresponse is blunted Centers for Disease Control and Prevention 1993 ; Sung et al. 2001 ; Royal College of Paediatrics and Child Health 2002 ; Allen 2007 ; Esposito et al. 2009 , 2010a ; Ruggiero et al. 2011 ; Kersun et al. 2013a . Multiple small studies have analyzed response to infl uenza vaccination, mainly during mainte- nance of ALL therapy and reviewed by Esposito et al. 2009 and Kersun et al. 2013a Allison et al. 1977 ; Sumaya et al. 1977 ; Ganz et al. 1978 ; Gross et al. 1978 ; Smithson et al. 1978 ; Lange et al. 1979 ; Schafer et al. 1979 ; Steinherz et al. 1980 ; Brydak et al. 1996 , 1998 ; Chisholm et al. 2001 ; Porter et al. 2004 ; Matsuzaki et al. 2005 ; Bektas et al. 2007 ; Shahgholi et al. 2010 ; Wong-Chew et al. 2012 ; Kersun et al. 2013a . In general, the vaccine was well tol- erated with no serious adverse side effects. When comparing response for patients receiv- ing chemotherapy versus patients off therapy and healthy controls, rate of seroconversion was lower in patients still receiving therapy. Additionally, response in patients with solid tumors was more similar to patients off therapy and healthy controls. Kersun et al. 2013b showed that ALL patients vaccinated during induction had an improved response compared to patients receiving the vaccine post-induction or in maintenance. Timing of immunization during an ALL maintenance cycle has not been studied to determine if the rate of response is improved when the vaccine is given sepa- rated from a 5-day steroid pulse. Additionally, patients are recommended to receive a two-shot series their fi rst year of immunization and sub- sequently one annual shot. It is unclear if there would be additional benefi t by continuing with a yearly two-shot series or increased dose while immunocompromised.16.7.5.2 2009 H1N1 Pandemic Vaccine Seven studies have reported on effi cacy of the
2009 H1N1 pandemic infl uenza vaccine Bate et al. 2010b ; Cheng et al. 2011 ; Yen et al. 2011 ; Hakim et al. 2012 ; Shahin et al. 2012 ; Leahy et al. 2013 ; Mavinkurve-Groothuis et al. 2013 . In general, response rates were increased after two doses of vaccine in those patients with solid tumors and in those not receiving treatment. For a mixed pediatric oncology cohort, seroresponse ranged from 25.6–100 Bate et al. 2010b ; Cheng et al. 2011 ; Yen et al. 2011 ; Hakim et al. 2012 ; Leahy et al. 2013 ; Mavinkurve-Groothuis et al. 2013 . Absolute lymphocyte counts greater than the upper limit of normal for age or ≥1.0– 1.5 x 10 9 L depending on the study were a sig- nifi cant factor in antibody response in three studies Yen et al. 2011 ; Hakim et al. 2012 ; Mavinkurve-Groothuis et al. 2013 . Leahy et al. 2013 showed signifi cantly improved seroposi- tivity in children who received the higher 0.5 mL dose on univariate but not multivariate analysis. No severe adverse reactions were noted in any of the studies. As with the annual trivalent infl uenza vaccine, clear data as to the most effi cacious tim- ing of immunization during ALL therapy, appro- priate dose and the need for one versus two doses of vaccine are lacking although repeated, higher doses appear most effective.16.7.5.3 Live Attenuated Infl uenza Vaccine
Two studies have been completed to measure sero- response and safety of the live attenuated infl u- enza vaccine LAIV in immunocompromised patients Carr et al. 2011 ; Halasa et al. 2011 . Halasa et al. 2011 conducted a small pilot study on the safety and immunogenicity of LAIV in mild to moderately immunocompromised chil- dren with cancer. Children with severe immunode- fi ciency as defi ned by an absolute neutrophil count ANC 0.5 x 10 9 L, concurrent high-dose steroid usage ≥2 mgkgday or CD4+ T-lymphocyte percentage 15 were excluded. The ten patients with hematologic malignancies and solid tumors who were immunized did not have any seriousParts
» Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Introduction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» History and Physical Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Defi ning the Risk for Serious
» Initial Laboratory Evaluation Diagnostic Evaluation
» Chest Radiography CXR A supine CXR may identify pleural effusions,
» Computed Tomography CT Radiographic Imaging
» Magnetic Resonance Imaging MRI
» Positron Emission Tomography PET
» Aspergillus Galactomannan GMN Biomarkers for Invasive
» 1,3-β- Biomarkers for Invasive
» Polymerase Chain Reaction PCR
» Viral Studies Diagnostic Evaluation
» Invasive Procedures: Diagnostic Evaluation
» Adult FN Guidelines Empiric Management
» Monotherapy Versus Combination Therapy
» Which Monotherapy to Choose A Cochrane review of antipseudomonal beta-
» Alterations in Initial Empiric FN Antibiotic Management
» Outpatient Management of FN Although there remains a lack of one uniform
» Choice of Empiric Antifungal Therapy
» Duration of Antimicrobial Empiric Management
» Endovascular Sources Empiric Management
» Adjunctive Treatment Empiric Management
» Emergence of Resistant Empiric Management
» Red Blood Cell Administration
» Granulocyte Transfusion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hemolytic Transfusion Risks of Blood Product
» Infection and Sepsis Risks of Blood Product
» Allergic Reactions Risks of Blood Product
» Febrile Nonhemolytic Risks of Blood Product
» Transfusion-Related Acute Risks of Blood Product
» Transfusion-Associated Risks of Blood Product
» Iron Overload Risks of Blood Product
» Laboratory Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» General Management Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Alkalinization Urinary alkalinization has been a long-standing
» Allopurinol Allopurinol inhibits xanthine oxidase, an enzyme
» Rasburicase Rasburicase, recombinant urate oxidase, converts
» Renal Interventions Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pathophysiology Superior Vena Cava
» History and Physical Exam SVCSSMS should be suspected in a patient
» Imaging Studies The diagnosis of SVCSSMS is often made on
» Other Studies Tissue is required to make a defi nitive diagnosis
» Treatment Superior Vena Cava
» History and Physical Exam Small pericardial effusions are frequently asymp-
» Imaging and Other Studies The presence of a pericardial effusion can be
» History and Physical Exam Many patients with small pleural effusions are
» Imaging Studies When a pleural effusion is suspected, a chest
» History and Physical Exam Patients with pheochromocytoma typically have
» Laboratory Studies The diagnosis of pheochromocytoma is best made
» Imaging Studies Clinical Presentation
» Pulmonary Leukostasis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Presentation Spinal Cord Compression
» Differential Diagnosis Spinal Cord Compression
» Imaging MRI of the spine can help narrow the differential
» Surgery Surgery in spinal cord compression can be uti-
» Radiation Therapy The advantages of external beam radiation ther-
» Outcomes Spinal Cord Compression
» Presentation Altered Mental Status
» Initial Management Altered Mental Status
» Metabolic The metabolic causes of AMS or seizure in pedi-
» Chemotherapy-Associated Neurotoxicity Differential Diagnosis
» Posterior Reversible Encephalopathy Syndrome
» Outcomes Altered Mental Status
» Initial Management Increased Intracranial
» Soft Tissue A large meta-analysis of published data suggests
» Cerebrospinal Fluid Hydrocephalus is an excess of CSF within the
» Hemorrhage and Thrombosis Differential Diagnosis
» Idiopathic Intracranial Hypertension Differential Diagnosis
» Presentation of Stroke Cerebrovascular Disease
» Differential Diagnosis Cerebrovascular Disease
» Etiology of Stroke in Pediatric
» Ischemic Stroke After an ischemic stroke is diagnosed, the patient
» Hemorrhagic Stroke Hematomas can expand over several hours from
» Acute Lymphoblastic Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Myelogenous Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Promyelocytic Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Chronic Myelogenous Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Tumor Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Leukapheresis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hyperhydration Other Treatment Modalities
» Hydroxyurea Other Treatment Modalities
» Cranial Irradiation Other Treatment Modalities
» Pseudohyperkalemia Hyperleukocytosis has been noted to cause pseudo-
» Pseudohypoxemia Due to the rapid consumption of oxygen by leu-
» Pseudohypoglycemia Consumption of glucose by excess leukocytes
» Pseudothrombocytosis Leukemic blast lysis can lead to cell fragmenta-
» Transfusion Practice with Other Supportive Care
» Anesthetic Procedures Other Supportive Care
» Neutropenic Enterocolitis Gastrointestinal Infection
» Perirectal Abscess Gastrointestinal Infection
» Gastrointestinal Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pancreatitis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Bowel Obstruction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Abdominal Compartment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» ALL Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Other Malignancies Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Central Venous Catheters Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diagnosis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nociceptive Pain Types of Pain
» Neuropathic Pain Types of Pain
» World Health Organization Pharmacologic Treatment
» Intermittent Opioid Use Pharmacologic Treatment
» Long-Acting Opioids Pharmacologic Treatment
» Breakthrough Dosing Pharmacologic Treatment
» Opioid Rotation Pharmacologic Treatment
» Patient-Controlled Analgesia Pharmacologic Treatment
» Constipation Side Effects of Opioids
» Nausea and Vomiting Nausea and vomiting are rare opioid side effects
» Pruritus Pruritus is a common side effect of opioid use
» Sedation Side Effects of Opioids
» Confusion and Agitation Renal and hepatic function should be checked
» Respiratory Depression When dosed appropriately, opioids rarely result
» Myoclonus Patients receiving very high doses of opioids for
» Urinary Retention Urinary retention can be caused by any opioid but
» Calcium Channel Blockers Neuropathic Pain
» Serotonin and Norepinephrine Neuropathic Pain
» Tricyclic Antidepressants Neuropathic Pain
» Interventional Techniques Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vincristine-Related Peripheral Oncology-Specifi c Pain
» Osteonecrosis Oncology-Specifi c Pain
» Post-lumbar Puncture Oncology-Specifi c Pain
» Mucositis Pain Oncology-Specifi c Pain
» Pathophysiology of Emesis Chemotherapy-Induced
» Principles of Emesis Control in the Cancer Patient
» Emetogenicity of Chemotherapy Chemotherapy-Induced
» Dopamine Receptor Antagonists Classes of Antiemetics
» Corticosteroids Classes of Antiemetics
» Cannabinoids The plant Cannabis contains more than 60 differ-
» Other Antiemetic Agents Antihistamines
» Alternative Therapies Ginger Classes of Antiemetics
» Management of CINV Management of CINV Table
» Special Considerations Anticipatory Nausea and Vomiting
» Radiation-Induced Nausea Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Initiation The initiation stage occurs immediately following
» Primary Damage Response Pathophysiology of Oral Mucositis
» Signal Amplifi cation Pathophysiology of Oral Mucositis
» Ulceration Ulceration is the phase with the most clinical sig-
» Healing Pathophysiology of Oral Mucositis
» Clinical Course of Oral Mucositis
» Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Palifermin Prevention and Treatment
» Low-Level Laser Therapy Prevention and Treatment
» Glutamine Prevention and Treatment
» Cryotherapy Prevention and Treatment
» Oral Care Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Infections Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nutrition Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Dietary Counseling Nutrition Intervention
» Appetite Stimulants Nutrition Intervention
» Enteral Tube Feeding Nutrition Intervention
» Parenteral Nutrition Nutrition Intervention
» Nutrition and Survivorship Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Neutropenia Hematologic Toxicity
» Management of Thrombocytopenia Hematologic Toxicity
» Management of Anemia Hematologic Toxicity
» Somnolence Syndrome Central Nervous System
» Lhermitte’s Sign Central Nervous System
» Skin Complications Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Mucositis Head and Neck
» Ear Complications Head and Neck
» Laryngeal Complications Head and Neck
» Dysphagia and Esophagitis Gastrointestinal
» Nausea, Vomiting and Anorexia
» Pneumonitis Major Organ Infl ammation
» Pericarditis Major Organ Infl ammation
» Hepatitis Major Organ Infl ammation
» Nephropathy Major Organ Infl ammation
» Cystitis Major Organ Infl ammation
» Risk Stratifi cation Prevention of Bacterial
» Adult Data Antimicrobial Approaches
» Pediatric Data Data regarding the utility of bacterial prophylaxis
» Risks of Prophylaxis Prevention of Bacterial
» Guidelines and Current Usage of Antibacterial Prophylaxis
» Protocols for Line Placement and Care
» Antibiotic and Ethanol Locks
» Chlorhexidine Cleansing Chlorhexidine gluconate CHG is a bactericidal
» Future Directions Prevention of Bacterial
» Risk Stratifi cation Prevention of Fungal
» Approaches to Antifungal Prophylaxis
» Guideline Recommendations for Antifungal Prophylaxis
» Limitations of Current Options for Antifungal Prophylaxis
» Risks of Prophylaxis Prevention of Fungal
» Biomarkers Prevention of Fungal
» Future Directions Prevention of Fungal
» Risk Stratifi cation Prevention of Pneumocystis
» Approaches to PCP Prophylaxis
» Summary of the Recommendations
» Future Directions Prevention of Pneumocystis
» Postexposure Chemoprophylaxis Prevention of Viral Infections
» Suppressive Therapy Prevention of Viral Infections
» Future Directions Prevention of Viral Infections
» Hand Hygiene Infection Control Practices
» Mandatory Vaccination Infection Control Practices
» Hospital Isolation Practices Infection Control Practices
» Visitor Screening Policies Infection Control Practices
» Work Restriction Infection Control Practices
» Cytomegalovirus CMV Status of Transfused Blood
» Treatment of Myelosuppression with
» Prevention of Febrile Neutropenia, Delay
» Treatment of Febrile Neutropenia
» Treatment of Myelosuppression Clinical Usage of Myeloid Growth Factors
» Comparison of Granulocyte Colony-Stimulating Factor
» Optimal Dosing Adult guidelines recommend dosing of 5 mcgkg
» Route of Administration Optimal Administration of Colony-Stimulating Factors
» Optimal Timing Optimal Administration of Colony-Stimulating Factors
» Erythropoietin Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Interleukin-11 Platelet Growth Factors
» Thrombopoietin Receptor Agonists Platelet Growth Factors
» Immune Status Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Status During Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Recovery After Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immunization Practice Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diphtheria, Tetanus, and Acellular Pertussis
» Pneumococcal Conjugate Vaccine Recommendations
» Hemophilus Infl uenzae Type b
» Inactivated Infl uenza Vaccine Although in a Cochrane review Goossen et al.
» 2009 H1N1 Pandemic Vaccine Seven studies have reported on effi cacy of the
» Live Attenuated Infl uenza Vaccine
» Meningococcal Conjugate Vaccine Recommendations
» Varicella Zoster Virus Recommendations
» Recommendations Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Treatment of Hypogammaglobulinemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vaccination of Household Contacts
» Peripherally Inserted Central Catheter
» External Tunneled Central Venous Catheter
» Implanted Port Types of Central Venous
» Catheter Insertion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Exit Site Infection Infection
» Prevention of Infection Infection
» Drug Precipitate or Lipid Residue Occlusion Thrombotic Occlusion
» Evaluation of Catheter- Related Thrombosis
» Treatment of Catheter- Related Thrombosis
» Special Considerations During Anticoagulation Therapy
» Contraindications of Anticoagulant Therapy
» Skin Antisepsis Catheter Maintenance
» Central Venous Catheter Dressings
» Hub Care Catheter Maintenance
» Central Venous Catheter Flushing and Locking
» Chlorhexidine Bathing Chlorhexidine has been shown to be effective in
» Antiseptic Needleless Connectors and Antiseptic
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