Immunocompromised Patients

  • Hilary Humphreys
  • Bob Winter
  • Mical Paul


The ominous prognosis of cancer patients with or without neutropenia in need of critical care has led to reservations with regard to admission of cancer patients to the ICU. However, significant improvements in ICU and in-hospital survival of cancer patients in ICU have been demonstrated in studies in recent years [1–4]. Risk factors for mortality have shifted from those related to the underlying condition to those related to the severity of acute illness similar to other critically-ill patients. Neutropenia per se and the underlying malignancy (solid and hematological) do not have an impact on the outcome of patients in ICU. Recent chemotherapy is associated rather with improved survival [3, 5–7], while organ dysfunction, severity of disease scores, need for vasopressor treatment, need for mechanical ventilation immediately or after noninvasive ventilation, no definite diagnosis and a non-infectious diagnosis are associated with mortality [1–3, 8]. Invasive aspergillosis is also associated with very high mortality rates in ICU (see below). In several studies, admission to ICU in the early stages of sepsis or other acute event was associated with better survival than admission later, after development of organ dysfunction. Performance status is perhaps the most important and only variable relating to the underlying condition that is correlated with ICU death. The prognosis remains guarded for certain cancer patients, including patients after allogeneic hematopoietic stem cell transplantation (HSCT) with active uncontrolled graft versus host disease, those with relapse of the primary disease after allogeneic HSCT and special cases of solid cancer including pulmonary carcinomatous lymphangitis and carcinomatous meningitis with coma [9].


Chronic Lymphocytic Leukemia Invasive Aspergillosis Allogeneic Hematopoietic Stem Cell Transplantation Adult Respiratory Distress Syndrome Lung Transplant Recipient 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Azoulay E, Thiery G, Chevret S, et al. The prognosis of acute respiratory failure in critically ill cancer patients. Medicine (Baltimore). 2004;83:360–70.CrossRefGoogle Scholar
  2. 2.
    Legrand M, Max A, Peigne V, et al. Survival in neutropenic patients with severe sepsis or septic shock. Crit Care Med. 2011;40(1):43–9.CrossRefGoogle Scholar
  3. 3.
    McGrath S, Chatterjee F, Whiteley C, Ostermann M. ICU and 6-month outcome of oncology patients in the intensive care unit. QJM. 2010;103:397–403.PubMedCrossRefGoogle Scholar
  4. 4.
    Rabbat A, Chaoui D, Montani D, et al. Prognosis of patients with acute myeloid leukaemia admitted to intensive care. Br J Haematol. 2005;129:350–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Souza-Dantas VC, Salluh JI, Soares M. Impact of neutropenia on the outcomes of critically ill patients with cancer: a matched case–control study. Ann Oncol. 2011;22:2094–100.PubMedCrossRefGoogle Scholar
  6. 6.
    Vandijck DM, Benoit DD, Depuydt PO, et al. Impact of recent intravenous chemotherapy on outcome in severe sepsis and septic shock patients with hematological malignancies. Intensive Care Med. 2008;34:847–55.PubMedCrossRefGoogle Scholar
  7. 7.
    Lecuyer L, Chevret S, Thiery G, Darmon M, Schlemmer B, Azoulay E. The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med. 2007;35:808–14.PubMedCrossRefGoogle Scholar
  8. 8.
    Soares M, Caruso P, Silva E, et al. Characteristics and outcomes of patients with cancer requiring admission to intensive care units: a prospective multicenter study. Crit Care Med. 2010;38:9–15.PubMedCrossRefGoogle Scholar
  9. 9.
    Azoulay E, Soares M, Darmon M, Benoit D, Pastores S, Afessa B. Intensive care of the cancer patient: recent achievements and remaining challenges. Ann Intensive Care. 2011;1:5.PubMedCrossRefGoogle Scholar
  10. 10.
    Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011;52:427–31.PubMedCrossRefGoogle Scholar
  11. 11.
    Perfect JR. The impact of the host on fungal infections. Am J Med. 2012;125:S39–51.PubMedCrossRefGoogle Scholar
  12. 12.
    Rhee CK, Kang JY, Kim YH, et al. Risk factors for acute respiratory distress syndrome during neutropenia recovery in patients with hematologic malignancies. Crit Care. 2009;13:R173.PubMedCrossRefGoogle Scholar
  13. 13.
    Stanworth SJ, Hyde C, Heddle N, Rebulla P, Brunskill S, Murphy MF. Prophylactic platelet transfusion for haemorrhage after chemotherapy and stem cell transplantation. Cochrane Database Syst Rev. 2004;CD004269.Google Scholar
  14. 14.
    Massey E, Paulus U, Doree C, Stanworth S. Granulocyte transfusions for preventing infections in patients with neutropenia or neutrophil dysfunction. Cochrane Database Syst Rev. 2009;CD005341.Google Scholar
  15. 15.
    Alejandria MM, Lansang MA, Dans LF, Mantaring JB. Intravenous immunoglobulin for treating sepsis and septic shock. Cochrane Database Syst Rev. 2002;CD001090.Google Scholar
  16. 16.
    Hentrich M, Fehnle K, Ostermann H, et al. IgMA-enriched immunoglobulin in neutropenic patients with sepsis syndrome and septic shock: a randomized, controlled, multiple-center trial. Crit Care Med. 2006;34:1319–25.PubMedCrossRefGoogle Scholar
  17. 17.
    Raanani P, Gafter-Gvili A, Paul M, Ben-Bassat I, Leibovici L, Shpilberg O. Immunoglobulin prophylaxis in hematopoietic stem cell transplantation: systematic review and meta-analysis. J Clin Oncol. 2009;27:770–81.PubMedCrossRefGoogle Scholar
  18. 18.
    van Lelyveld SF, Wind CM, Mudrikova T, van Leeuwen HJ, de Lange DW, Hoepelman AI. Short- and long-term outcome of HIV-infected patients admitted to the intensive care unit. Eur J Clin Microbiol Infect Dis. 2011;30:1085–93.PubMedCrossRefGoogle Scholar
  19. 19.
    Huang L, Quartin A, Jones D, Havlir DV. Intensive care of patients with HIV infection. N Engl J Med. 2006;355:173–81.PubMedCrossRefGoogle Scholar
  20. 20.
    Boulware DR, Meya DB, Bergemann TL, et al. Clinical features and serum biomarkers in HIV immune reconstitution inflammatory syndrome after cryptococcal meningitis: a prospective cohort study. PLoS Med. 2010;7:e1000384.PubMedCrossRefGoogle Scholar
  21. 21.
    Zolopa A, Andersen J, Powderly W, et al. Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial. PLoS One. 2009;4:e5575.PubMedCrossRefGoogle Scholar
  22. 22.
    Havlir DV, Kendall MA, Ive P, et al. Timing of antiretroviral therapy for HIV-1 infection and tuberculosis. N Engl J Med. 2011;365:1482–91.PubMedCrossRefGoogle Scholar
  23. 23.
    Abdool Karim SS, Naidoo K, Grobler A, et al. Timing of initiation of antiretroviral drugs during tuberculosis therapy. N Engl J Med. 2010;362:697–706.PubMedCrossRefGoogle Scholar
  24. 24.
    Manosuthi W, Mankatitham W, Lueangniyomkul A, et al. Time to initiation of antiretroviral therapy between 4 weeks and 12 weeks of tuberculosis treatment in HIV-1 infected patients. Results from the TIME Study. In: Paper presented at the 22nd European Congress of clinical microbiology and infectious diseases, London. 2012. Abstract no. ESCMID.Google Scholar
  25. 25.
    Torok ME, Yen NT, Chau TT, et al. Timing of initiation of antiretroviral therapy in human immunodeficiency virus (HIV)–associated tuberculous meningitis. Clin Infect Dis. 2011;52:1374–83.PubMedCrossRefGoogle Scholar
  26. 26.
    Makadzange AT, Ndhlovu CE, Takarinda K, et al. Early versus delayed initiation of antiretroviral therapy for concurrent HIV infection and cryptococcal meningitis in sub-saharan Africa. Clin Infect Dis. 2010;50:1532–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Marik PE, Kiminyo K, Zaloga GP. Adrenal insufficiency in critically ill patients with human immunodeficiency virus. Crit Care Med. 2002;30:1267–73.PubMedCrossRefGoogle Scholar
  28. 28.
    Aguilar-Guisado M, Givalda J, Ussetti P, et al. Pneumonia after lung transplantation in the RESITRA Cohort: a multicenter prospective study. Am J Transplant. 2007;7:1989–96.PubMedCrossRefGoogle Scholar
  29. 29.
    Mattner F, Kola A, Fischer S, et al. Impact of bacterial and fungal donor organ contamination in lung, heart-lung, heart and liver transplantation. Infection. 2008;36:207–12.PubMedCrossRefGoogle Scholar
  30. 30.
    Vandecasteele E, De Waele J, Vandijck D, et al. Antimicrobial prophylaxis in liver transplant patients–a multicenter survey endorsed by the European Liver and Intestine Transplant Association. Transpl Int. 2010;23:182–90.PubMedCrossRefGoogle Scholar
  31. 31.
    Satoi S, Bramhall SR, Solomon M, et al. The use of liver grafts from donors with bacterial meningitis. Transplantation. 2001;72:1108–13.PubMedCrossRefGoogle Scholar
  32. 32.
    Bahrami T, Vohra HA, Shaikhrezai K, et al. Intrathoracic organ transplantation from donors with meningitis: a single-center 20-year experience. Ann Thorac Surg. 2008;86:1554–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Gonzalez Segura C, Pascual M, Garcia Huete L, et al. Donors with positive blood culture: could they transmit infections to the recipients? Transplant Proc. 2005;37:3664–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Lumbreras C, Sanz F, Gonzalez A, et al. Clinical significance of donor-unrecognized bacteremia in the outcome of solid-organ transplant recipients. Clin Infect Dis. 2001;33:722–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Bollee G, Sarfati C, Thiery G, et al. Clinical picture of P. jirovecii pneumonia in cancer patients. Chest. 2007;132:1305–10.PubMedCrossRefGoogle Scholar
  36. 36.
    Ponce CA, Gallo M, Bustamante R, Vargas SL. Pneumocystis colonization is highly prevalent in the autopsied lungs of the general population. Clin Infect Dis. 2010;50:347–53.PubMedCrossRefGoogle Scholar
  37. 37.
    Limper AH, Knox KS, Sarosi GA, et al. An official American Thoracic Society statement: treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011;183:96–128.PubMedCrossRefGoogle Scholar
  38. 38.
    Safrin S, Lee BL, Sande MA. Adjunctive folinic acid with trimethoprim-sulfamethoxazole for Pneumocystis carinii pneumonia in AIDS patients is associated with an increased risk of therapeutic failure and death. J Infect Dis. 1994;170:912–7.PubMedCrossRefGoogle Scholar
  39. 39.
    Dutkiewicz R, Hage CA. Aspergillus infections in the critically ill. Proc Am Thorac Soc. 2010;7:204–9.PubMedCrossRefGoogle Scholar
  40. 40.
    De Pauw B, Walsh TJ, Donnelly JP, et al. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clin Infect Dis. 2008;46:1813–21.PubMedCrossRefGoogle Scholar
  41. 41.
    Mengoli C, Cruciani M, Barnes RA, Loeffler J, Donnelly JP. Use of PCR for diagnosis of invasive aspergillosis: systematic review and meta-analysis. Lancet Infect Dis. 2009;9:89–96.PubMedCrossRefGoogle Scholar
  42. 42.
    Sun W, Wang K, Gao W, et al. Evaluation of PCR on bronchoalveolar lavage fluid for diagnosis of invasive aspergillosis: a bivariate metaanalysis and systematic review. PLoS One. 2011;6:e28467.PubMedCrossRefGoogle Scholar
  43. 43.
    Leeflang MM, Debets-Ossenkopp YJ, Visser CE, et al. Galactomannan detection for invasive aspergillosis in immunocompromized patients. Cochrane Database Syst Rev. 2008;CD007394.Google Scholar
  44. 44.
    Guo YL, Chen YQ, Wang K, Qin SM, Wu C, Kong JL. Accuracy of BAL galactomannan in diagnosing invasive aspergillosis: a bivariate metaanalysis and systematic review. Chest. 2010;138:817–24.PubMedCrossRefGoogle Scholar
  45. 45.
    Walsh TJ, Anaissie EJ, Denning DW, et al. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2008;46:327–60.PubMedCrossRefGoogle Scholar
  46. 46.
    Trifilio S, Pennick G, Pi J, et al. Monitoring plasma voriconazole levels may be necessary to avoid subtherapeutic levels in hematopoietic stem cell transplant recipients. Cancer. 2007;109:1532–5.PubMedCrossRefGoogle Scholar
  47. 47.
    Caillot D, Thiebaut A, Herbrecht R, et al. Liposomal amphotericin B in combination with caspofungin for invasive aspergillosis in patients with hematologic malignancies: a randomized pilot study (Combistrat trial). Cancer. 2007;110:2740–6.PubMedCrossRefGoogle Scholar
  48. 48.
    Garbati MA, Alasmari FA, Al-Tannir MA, Tleyjeh IM. The role of combination antifungal therapy in the treatment of invasive aspergillosis: a systematic review. Int J Infect Dis. 2012;16:e76–81.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2013

Authors and Affiliations

  • Hilary Humphreys
    • 1
  • Bob Winter
    • 2
  • Mical Paul
    • 3
  1. 1.Beaumont Hospital The Royal College of Surgeons in IrelandDublinIreland
  2. 2.Queen’s Medical Centre University Hospital NottinghamNottinghamUK
  3. 3.Rabin Medical Center Beilinson Hospital Unit of Infectious Diseases Sackler Faculty of Medicine Tel-Aviv UniversityPetach Tikva/Tel-AvivIsrael

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