Intravenous Immunoglobulin (IVIG)

Intravenous Immunoglobulin (IVIG)

PEP Topic 
Prevention of Infection: Transplant
Description 

Immunoglobulin is an antibody in the immune system that identifies and neutralizes foreign items, such as bacteria and viruses. It is part of the humoral immune system. Prophylactic intravenous administration of immunoglobulin (IVIG) has been examined in patients with cancer for prevention of infection. In general, consideration of IVIG is only suggested by the NCCN guidelines for patients with significant hypogammaglobulinemia.

Benefits Balanced With Harm

Guideline/Expert Opinion

National Comprehensive Cancer Network. (2011). NCCN Clinical Practice Guidelines in Oncology: Prevention and treatment of cancer-related infections [v.2.2011]. Retrieved from https://subscriptions.nccn.org/gl_login.aspx?ReturnURL=http://www.nccn.org/professionals/physician_gls/pdf/infections.pdf

http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#detection
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Purpose & Patient Population:

To provide guidance for clinical practices for the prevention and treatment of infection in patients with cancer.

Type of Resource/Evidence-Based Process:

This resource is a consensus-based guideline.

Phase of Care and Clinical Applications:

Patients were undergoing the active antitumor treatment phase of care.

Guidelines & Recommendations:

The guideline

  • Recommends the consideration of general antibacterial prophylaxis in patients at intermediate and high risk for infection, consideration of antifungal prophylaxis during neutropenia and for anticipated mucosits, and antiviral prophylaxis for intermediate- and high-risk patients.
  • Provides suggestions for specific agents for prophylaxis and treatment in various clinical scenarios.
  • Outlines treatment and diagnostic/assessment approaches for neutropenic fever and specific clinical presentations.
  • Notes that chlorhexidine and sliver sulfadiazine-coated short-term central catheters have been shown to decrease the incidence of catheter colonization and bloodstream infections, but not in patients with hematologic malignancies requiring indwelling catheters for approximately 20 days.
  • Notes that vaccination recommendations for transplantation recipients and their household members should be performed.
  • Recommends the pneumococcal vaccine in asplenic patients.

The National Comprehensive Cancer Network (NCCN) does not currently endorse the use of a vancomycin lock solution for long-term vascular access devices due to concerns about the emergence of bacterial resistance if widely used. Influenza vaccination with a vaccine that does not use live attenuated organisms can be safely given, and the guideline recommends administration at least two weeks before receiving cytotoxic therapy.

Limitations:

This study lacked high-quality evidence, with most recommendations being based on consensus.

Nursing Implications:

This guideline provided comprehensive references to assess patient risk of infection and expert recommendations regarding interventions aimed at the prevention and treatment of infection in patients with cancer. The guideline does not discuss long-term survivorship issues in this area.

Rizzo, J. D., Wingard, J. R., Tichelli, A., Lee, S. J., Van Lint, M. T., Burns, L. J., . . . Socié, G. (2006). Recommended screening and preventive practices for long-term survivors after hematopoietic cell transplantation: joint recommendations of the European Group for Blood and Marrow Transplantation, the Center for International Blood and Marrow Transplant Research, and the American Society of Blood and Marrow Transplantation. Biology of Blood and Marrow Transplantation, 12, 138–151.

doi: 10.1016/j.bbmt.2005.09.012
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Purpose & Patient Population:

To summarize recommendations for care providers regarding screening and prevention practices for adult autologous and allogeneic hematopoietic cell transplantation survivors.

Type of Resource/Evidence-Based Process:

This was classified as an expert opinion.

Recommended practices were developed by a consensus panel from three major blood and marrow transplantation organizations. Most recommendations were developed from studies (not cited) identifying specific complications and associated risk factors in long-term survivors.

Phase of Care and Clinical Applications:

  • Patients were undergoing long-term follow-up care.
  • The study has clinical applicability for late effects and survivorship. 

Guidelines & Recommendations:

Guidelines for the prevention of infection for all transplantation patients include Pneumocystis carinii pneumonia prophylaxis for six months and immunization with inactivated vaccines beginning at one year posttransplantation and annually thereafter.  Other infection prevention recommendations include antibiotic prophylaxis for encapsulated microorganisms during immunosuppressive therapy for chronic graft-versus-host disease (cGVHD), possible antifungal prophylaxis for patients on chronic steroids, adhering to the American Heart Association (AHA) guidelines of antibiotic prophylaxis for oral procedures, cytomegalovirus antigen or polymerase chain reaction testing for allogeneic hematopoietic cell transplantation recipients with chronic immunosuppression or cGVHD, and possible prophylaxis for the herpes simplex virus for those on chronic immunosuppressants for cGVHD. This article also includes recommendations for many other aspects of posttransplantation care. Recommendations are summarized in two tables, one organized by body system and the other organized by time after transplantation.

Limitations:

The authors did not include the sources used to arrive at the consensus recommendations, with the following exceptions:

  • Recommendations for prophylactic antibiotics for oral procedures follow the AHA guidelines for endocarditis prophylaxis.
  • Recommendations for annual vaccinations follow either the Center for Disease Control guidelines or the European Group for Blood and Marrow Transplantation guidelines.

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