Infectious Complications

Patients with CLL are at an increased risk of infection due to being immunocompromised as a result of the disease and/or treatment (Hallek et al., 2008). Up to 50% of CLL-related deaths are due to infectious complications (Oscier et al., 2012). Therefore, appropriate screening and prevention of infection in CLL is recommended (NCCN, 2017; Oscier et al., 2012).

Because infections are a common complication in CLL, use of immunosuppressive agents including corticosteroids should be restricted (Eichhorst et al., 2017). ESMO Clinical Practice Guidelines recommend that antibiotics should be used in patients with recurrent infections and/or at very high risk of developing infections. This includes Pneumocystis prophylaxis with co-trimoxazole during treatment with chemoimmunotherapy with purine analogues or bendamustine (Eichhorst et al., 2017) or idelalisib (EMA, 2016).

In brief, the UK guidelines recommend (Oscier et al., 2012):

  • Antimicrobial prophylaxis in cases of hypogammaglobulinaemia or recurrent bacterial infections.
  • Anti-Pneumocystis jirovecii prophylaxis in patients requiring intensive and/or immunosuppressive treatment and idelalisib.
  • Anti-herpes simplex virus and herpes zoster virus prophylaxis in patients needing intensive and/or immunosuppressive treatment, who are seropositive, have low CD4 count or have had prior herpes infection.
  • No general prophylaxis is recommended for patients receiving alkylating agents or bendamustine, but individual decisions (based on history) are advised. Use of prophylaxis is controversial for patients receiving FC or FCR first line therapy and may not be necessary.
  • GCSF, given according to recommended guidelines.
  • Monitoring for cytomegalovirus (CMV) reactivation should be carried out in patients receiving idelalisib.
  • Patients receiving immunosuppressive therapy should be screened prior to treatment for hepatitis B or C infection. Patients who are positive for either may need antiviral treatment and should be managed in conjunction with a specialist in viral hepatitis.
  • Consideration of Epstein-Barr virus (EBV) reactivation in febrile CLL especially if high risk CLL.
  • Progressive multifocal leukoencephalopathy (PML) is a rare complication associated with rituximab treatment, therefore PML should be considered in patients developing confusion, weakness, poor motor coordination, speech or visual changes.
  • Patient education should be undertaken regarding the risk of infection.