Tomorrow Dr Ludwig and I will cover the issue of infections in patients with multiple myeloma. Dr Ludwig will be presenting the theoretical part and I will be presenting two cases illustrating the infectious complications in patients with multiple myeloma. In these two real cases we have a number of questions for the audience. So this will be how the workshop will go tomorrow.
What are the questions to be addressed?
The issue is more than the questions, it will be the issues related with infections – the frequency, the type, the prophylaxis and the treatment of the infections in patients with multiple myeloma in different situations. Myeloma itself places the patient at risk of infection. In fact, about 10% of patients with multiple myeloma are diagnosed with an infection due to an infectious complication, particularly pulmonary infections, pneumococcal pneumonia and so on. Then over the course of active disease the patients have an increased rate of infections. In fact, infection is the more frequent cause of death, either at the beginning in patients with high risk and also at the end of the disease, particularly bacterial infections.
So the prophylaxis and the treatment is crucial and now with novel agents, particularly with proteasome inhibitors, bortezomib, carfilzomib, ixazomib, prophylaxis against viral infections, particularly herpes zoster infections and varicella infections and so on is essential with azacitidine. So this is that. And then there is the issue of vaccination – vaccination against pneumococcal pneumonia, vaccinations against Haemophilus influenza and the flu. Also the issue of if to use or not to use high dose immunoglobulins in patients with very frequent bacterial, particularly pneumococcal, infections. All these will be discussed tomorrow.
What measures can be taken to help prevent infection?
In preventing infections there are patients who are at higher risk than usual. Those who are diagnosed in hospital, particularly old women, are prone to urinary infections. Also patients with renal failure, also patients with IgG myeloma with a very high level of IgG monoclonal with decreased uninvolved immunoglobulins, these are the highest risk. These patients, at least for the two first amounts of treatment, need infection prophylaxis with septrin or levofloxacin; this is the prophylaxis that these particular patients need. Young patients, outpatients, these patients don’t need prophylaxis because the rate of infection is very low and when the patient is in the plateau phase, in stable response, these patients don’t have an increased risk of infection. But when the patient relapses, again particularly if there is renal failure, high levels of IgG and so on, these patients are prone again to infection. So then we need prophylaxis again.