Stanford supportive care guidelines for managing infectious risk following CAR19
| Antimicrobial prophylaxis . | Clinical/laboratory monitoring . |
|---|---|
| PJP | CD4+T-cell count |
| Start 1500 mg atovaquone, daily, on day 14. | Assess at 1 y, and then every 3-6 mo until stably >200 cells per μL. |
| If ongoing grade ≥3 cytopenia(s) after day 28, | |
| • continue atovaquone for 18 mo or until CD4+ count >200 cells per μL when monitoring is available. | |
| If no grade ≥3 cytopenia(s) after day 28, | |
| • change to TMP-SMX, 80-400 mg daily, for 18 mo or until CD4+ count >200 cells per μL when monitoring is available. | |
| HSV/VZV | CMV |
| Start 800 mg acyclovir or 500 mg valacyclovir twice a day prior to LD, and continue for ≥18 mo, or 6 mo beyond last episode of HSV or VZV. | If patient has received ≥5 d of corticosteroids, |
| • assess blood qPCR and continue weekly until undetectable. | |
| If rising viral load or symptomatic, | |
| • evaluate for end-organ involvement. | |
| IVIG | Serum IgG level |
| If patient has sinopulmonary infection(s) and IgG <400 mg/dL, | If asymptomatic, |
| • give IVIG, 0.5 g/kg body weight, and reassess monthly for continued replacement need | • assess at day 28, and then every 3-6 mo until consistently >400 mg/dL. |
| If patient develops sinopulmonary infection(s), | |
| • reassess every 2-3 mo; consider IVIG if <400 mg/dL. | |
| HBV | Viral screening |
| If patient has positive HBsAg, HBcAb, or HBV DNA, | Assess all patients prior to apheresis with serologic and/or qPCR testing for HIV, viral hepatitis (A/B/C). |
| • start 0.5 mg entecavirdaily prior to LD, and continue for ≥12 mo or until CD4+ count >200 cells per μL. | |
| Candida | Invasive mold infection |
| If patient has severe (grade ≥3) mucositis, | If patient has known history of invasive mold infection, |
| • start 400 mg fluconazole daily on day 0, and continue until ANC >1000 cells per μL. | • start 300 mg posaconazoledaily prior to LD, and continue for ≥30 d, or 1 mo beyond ANC >1000 cells per μL. |
| Antimicrobial prophylaxis . | Clinical/laboratory monitoring . |
|---|---|
| PJP | CD4+T-cell count |
| Start 1500 mg atovaquone, daily, on day 14. | Assess at 1 y, and then every 3-6 mo until stably >200 cells per μL. |
| If ongoing grade ≥3 cytopenia(s) after day 28, | |
| • continue atovaquone for 18 mo or until CD4+ count >200 cells per μL when monitoring is available. | |
| If no grade ≥3 cytopenia(s) after day 28, | |
| • change to TMP-SMX, 80-400 mg daily, for 18 mo or until CD4+ count >200 cells per μL when monitoring is available. | |
| HSV/VZV | CMV |
| Start 800 mg acyclovir or 500 mg valacyclovir twice a day prior to LD, and continue for ≥18 mo, or 6 mo beyond last episode of HSV or VZV. | If patient has received ≥5 d of corticosteroids, |
| • assess blood qPCR and continue weekly until undetectable. | |
| If rising viral load or symptomatic, | |
| • evaluate for end-organ involvement. | |
| IVIG | Serum IgG level |
| If patient has sinopulmonary infection(s) and IgG <400 mg/dL, | If asymptomatic, |
| • give IVIG, 0.5 g/kg body weight, and reassess monthly for continued replacement need | • assess at day 28, and then every 3-6 mo until consistently >400 mg/dL. |
| If patient develops sinopulmonary infection(s), | |
| • reassess every 2-3 mo; consider IVIG if <400 mg/dL. | |
| HBV | Viral screening |
| If patient has positive HBsAg, HBcAb, or HBV DNA, | Assess all patients prior to apheresis with serologic and/or qPCR testing for HIV, viral hepatitis (A/B/C). |
| • start 0.5 mg entecavirdaily prior to LD, and continue for ≥12 mo or until CD4+ count >200 cells per μL. | |
| Candida | Invasive mold infection |
| If patient has severe (grade ≥3) mucositis, | If patient has known history of invasive mold infection, |
| • start 400 mg fluconazole daily on day 0, and continue until ANC >1000 cells per μL. | • start 300 mg posaconazoledaily prior to LD, and continue for ≥30 d, or 1 mo beyond ANC >1000 cells per μL. |
CMV, cytomegalovirus; HBcAb, hepatitis B core antibody; HBsAG, hepatitis B surface antigen; HBV, hepattis B virus; HSV, herpes simplex virus; qPCR, quantitative polymerase chain reaction assay; VZV, varicella-zoster virus.