Caring for an Immunocompromised Bone Marrow Transplant Recipient

Bone marrow transplantation (BMT) is a common treatment for advanced hematologic malignancies. During the process, the patient’s hematologic system is eradicated using chemotherapy and radiation therapy. The type of transplant a patient receives is dependent on their diagnosis and/or comorbidities.

An autologous transplant will require mobilization of stem cells. This is achieved by administration of chemotherapy and/or growth factors. Recovery is usually quicker with less complications. Allogeneic transplant is replaced with healthy hematopoietic cells from a human leukocyte antigen–matched donor to constitute a new blood-forming system. The lengthy process can be grueling, and BMT recipients typically become immunocompromised. As a result of myelosuppression, patients are at increased risk of neutropenia.¹

Special protocols are required to minimize the patient’s risk of infection and to treat or prevent adverse effects. Oncology nurses typically provide prophylactic anti-infection measures and educate patients and caregivers about the protocols they must follow. These measures may include the following:

Supportive Care^1-3

• Antimicrobials such as ciprofloxacin (CiproXR), penicillin v potassium, and trimethoprim-sulfamethoxazole (Bactrim) given prophylactically
• Antivirals such as acyclovir (Sitavig, Zovirax), valacyclovir (Valtrex), and ganciclovir (Zirgan) to prevent herpes simplex virus and cytomegalovirus infections
• Antifungals, including fluconazole (Diflucan), voriconazole (Vfend, Vfend IV), and posaconazole (Noxafil)
• Antiemetics to prevent or treat nausea and vomiting
• Electrolyte supplements to maintain normal potassium, magnesium, calcium, and phosphorus levels
• Granulocyte colony-stimulating factor is given to shorten the time to engraftment
• Transfusions of red blood cells and platelets in the early posttransplant period to treat thrombocytopenia and anemia until the bone marrow graft begins to produce new blood cells

Treating and Preventing Mucositis^4,5

• Inflammation or excoriation of the oral mucosa and the gastrointestinal tract because of pretransplant chemotherapy or radiation therapy manifests as stomatitis and dysphagia, which can reduce quality of life, prolong the hospital stay, and raise infection risk. Antioral mucositis measures include the following:
• Cryotherapy (ice chips or ice pops) before, during, and after melphalan administration for a total of 2 hours to induce vasoconstriction and slow melphalan absorption
• Calcium phosphate (Caphosol) mouth rinse and Magic Mouthwash (diphenhydramine [Benedryl], aluminum hydrozide/magnesium hydroxide/simethicone [Mylanta], and lidocaine viscous) to soothe the oral mucosa

Managing Digestive Adverse Effects⁶

Preventive treatment should start before chemotherapy or radiation treatment and continue as needed.

Nausea/vomiting. Use antiemetics as needed and replete fluids and electrolytes. Patients may benefit from eating smaller meals more frequently, avoiding fatty foods, eating drier foods with fluids in between, and consuming saltier foods, such as crackers and pretzels.

Diarrhea. Patient’s stool should be tested for Clostridium difficile. Use antidiarrheal medications and replete fluids/electrolytes as needed. High-fiber foods, nuts, seeds, fatty or fried foods, spicy foods, caffeinated beverages, foods containing sorbitol or lactose, and sugar substitutes should be limited. Daily fluid intake should be 8 to 10 cups.

Anorexia. Patients should consult with a registered dietitian before, during, and after transplant as needed.

Taste/smell changes. Maintaining good oral hygiene helps improve the taste of foods. Patients may enjoy tart foods, such as lemon, yogurt, and pineapple.

Prevention and Treatment of Complications^7,8

Graft-vs-host disease (GVHD) occurs when donor cells recognize the recipient’s tissues as foreign and mount an attack, which can be life-threatening. GVHD most commonly causes irritation of the skin, liver, gastrointestinal tract, and lungs. Acute GVHD occurs from a few days after transplant up to day 90 posttransplantation. Chronic GVHD persists from day 90 and beyond. Immunosuppressant medications, such as steroids, methotrexate (Trexall), cyclosporine (Sandimmune, Neoral, Gengraf), and tacrolimus (Prograf), are given to reduce GVHD severity.

Hepatic veno-occlusive disease (VOD) primarily affects allogeneic transplant recipients with preexisting liver disease and GVHD. Small blood vessels in the liver become injured and occluded, causing ascites, weight gain, and jaundice. This life-threatening condition is commonly seen in the patients who receive melphalan, cyclophosphamide, and busulfan during pretransplant conditioning. Early diagnosis of VOD decreases morbidity and mortality rates.

Interstitial pneumonitis is lung inflammation, occurring as early as the first 100 days posttransplant. Late-onset pneumonitis can arise up to 2 years posttransplant. Pneumonitis can be induced by GVHD, chemotherapy, or radiation. Early diagnosis and treatment are essential.

Psychosocial Health⁹

A psychosocial assessment should be performed before and after transplant to address each patient’s ongoing emotional and practical needs. Examples include caregiver support, financial concerns, medication adherence, child care, sexuality, housing, and transportation.

Hospital Discharge Criteria

• Absolute neutrophil count of at least 500 to 1,000 mm³
• No fever for 48 hours
• Hematocrit of at least 25% to 30%
• Plate count of at least 15,000 to 20,000 mm³
• Nausea, vomiting, and diarrhea are controlled
• Able to swallow medications and keep them down for 48 hours
• Caregiver at home in a safe and supportive environment

Patient and Caregiver Education^10-12

Education of patients and their caregivers is a vital role of the oncology nurse on the BMT service to help transplant recipients optimize their health. To reduce the risk of infection and complications, patients should practice the following:

• Wash hands thoroughly
• Use a face mask in public
• Take temperature twice daily and record it
• Shower daily
• Keep venous catheter dry
• Use a soft toothbrush and nonwhitening toothpaste
• Avoid flossing if the patient did not regularly floss before transplant
• Follow a low-microbial diet (no aged cheeses and unpasteurized foods, all foods well cooked)
• Use electric razors only
• No driving immediately after transplant, and patients should ride in the back seat if platelet count is less than 50,000
• Report any new rash
• Avoid close contact with people with respiratory illness symptoms
• Avoid crowded areas
• Avoid direct contact with soil and plants, which increases exposure to potential pathogens
• Avoid cleaning cat litter and scooping dog feces

When to Call the Doctor

Advise patients to contact their physician if they experience any of the following:

• Fever of 100.4o F or more, even if they feel well
• Cough with yellow or green sputum
• Sinus draining
• Sore throat or painful swallowing
• Shortness of breath or changes in breathing
• Uncontrolled nausea, vomiting, or diarrhea
• Any skin breakdown
• Trouble urinating
• Cloudy/foul urine
• Easy bruising and bleeding
• Sudden confusion
• Headaches

References

1. Stem cell or bone marrow transplant. American Cancer Society. Accessed February 23, 2022. https://bit.ly/36C9cqn
2. Preventing infection after bone and marrow transplant. Cleveland Clinic. Updated August 8, 2019. Accessed February 23, 2022. https://cle.clinic/3vtWBA1
3. Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: ASCO Guideline Update. J Clin Oncol. 2020;(38)24:2782-2797. doi:10.1200/JCO 20.01296
4. Cryotherapy against oral mucositis after high-dose melphalan. ClinicalTrials.gov. Updated October 15, 2018. Accessed February 23, 2022. https://bit.ly/3pcgmrH
5. Younus J, Kligman L, Jawaid MA, Dhalla A. Treatment of active mucositis with caphosol (calcium phosphate): a retrospective case-series. World J Oncol. 2013;4(3):147-150. doi:10.4021/wjon683e
6. Alonso CD, Marr KA. Clostridium difficile infection among hematopoietic transplant recipients: beyond colitis. Curr Opin Infect Dis.2013;(26)4:326-331. doi:10.1097/QCO.0b013e3283630c4c
7. Dalle JH, Giralt SA. Hepatic veno-occlusive disease after hematopoietic stem cell transplantation: risk factors and stratification, prophylaxis, and treatment. Biol Blood Marrow Transplant. 2016;22(3):400-409. doi:10.1016/j.bbmt.2015.09.024
8. Graft-versus-host disease. National Cancer Institute. Accessed February 23, 2022. https://bit.ly/36ulqBf
9. Cooke L, Gemmill R, Kravits K, Grant M. Psychological issues of stem cell transplant. Semin Oncol Nurs.2009;25(2):139-150. doi:10.1016/j.soncn.2009.03.008
10. Wingard JR, Vogelsang GH, Deeg HJ. Stem cell transplantation: supportive care and long-term complications. Hematology Am Soc Hematol Educ Program.2002:422-444. doi:10.1182/asheducation-2002.1.422
11. Caregiver’s role in nutrition. Leukemia and Lymphoma Society. Accessed February 23, 2022. https://bit.ly/3h7drfE
12. Eating hints: before, during, and after cancer treatment. National Cancer Institute. October 17, 2014. Accessed February 23, 2022. https://bit.ly/3sc8hW0