How long will I be immunocompromised? How can I prevent infection after transplant?

How long will I be immunocompromised?

The, biggest risk period is for about, a week after the transplant, where the blood counts are very, very low. And, the gut has been damaged by the male. So in chemotherapy, there's lots of bacteria that live within our intestines. So most patients that get infections during that period, they have translocation of bacteria from their intestine into their bloodstream through little holes that have been created by the damage from the chemotherapy.

So that's the biggest period of immuno compromised upfront. Once the blood counts have recovered, patients, are generally in a much better place as far as their immune system, but there are probably still some holes in their immune system. Their ability to fight viruses, is not as strong. And so they, they're, they might be more susceptible to colds and flus.

Typically, after the transplant procedure, we, start vaccinating them for, diseases that, you know, are typically, seen in childhood, like diphtheria, pertussis, and they go through a series of vaccination and, over a period of two years, the other, viruses that can be problematic are herpes viruses. So cold sores, shingles can be a problem.

There is a new shingles vaccine that can be administered early after the procedure. That can decrease the risk of shingles reactivation. We also recommend prophylaxis with antivirals, for at least one year after the transplant procedure, because that's the main one we worry about. But most of the time, about a month after the transplant, I let my patients travel.

I let them get back to their life to do what they want to do, because that's why they went through the transplant procedure to get back to their lives. We do caution them about, avoiding certain foods like moldy cheese and things that are not cooked very well, but washing hands and avoiding sick contacts usually most people, don't have any major difficulties with, immunocompromised.

How long should patients avoid crowds?

I let them go out into public very early after the procedure. So as long as soon as they're discharged from our transplant program, which sometimes is day 18 and 15 to 18 after the procedure. You know, I tell them they can, you know, they can drive, they can go to the grocery store. I do tell them to avoid large crowds like football games because, again, the more people you're in contact with, the more likely you're, you're going to acquire something.

Some people are need to travel to get back to their home. So, patients routinely go to the airport. There's lots of people there. We tell them to try to avoid the big crowds and, you know, washing the hands by and by far the number one thing that they can do to avoid infections. So having some Purell or some sort of antibacterial lotion on them at all times and being very anal about that, goes a very long way to preventing complications.

Immunocompromised myeloma and immunocompromised after transplant are really hard to put a finger on right now. I think that with the Covid 19 pandemic, we realize that we don't understand it as well as we could. Certainly in the context of transplant, you can use the white blood cell count and the neutrophil count as a marker of the, robustness of the immune system.

So when a patient's white blood cell count recovers after transplant, that's considered to be a milestone where patients are given some additional freedoms as far as the amount of protection that they need in that immediate period of time, even though the white blood cell count recovers, though the immune system has not fully recovered, and it's usually months until we think that somebody's immune system has gotten close to normal, it's impossible, in my opinion, to take a group of patients who have had transplants at different times and have had different types of treatments before transplant, and to line them all up in order of most immunocompromised to least immunocompromised.

And I wish we could do that because people really want to know the answer, can I do this or can I do that? And I think the truth is that you just have to try to be be someone who uses your best judgment and try to be reasonable. I think remaining cautious for the first couple of months after transplant, trying to remain in a reasonably protective environment where you're not in the thick of things, where you're not with a lot of people who clearly have upper respiratory infections, makes a lot of sense.

But I do think it's okay for people to go to important family or community events, even though they might have some degree of of weakening of their immune system.

Are any prophylactic medications recommended to prevent infections after transplant?

We do give patients, bacterial prophylaxis so particular kinds of antibiotics when the neutrophil count is very low. We also give people antivirals to help prevent against zoster infections. And then we also give people a particular type of antibiotic to help prevent it, prevent a kind of pneumonia that can occur, with prolonged immunosuppression.

What should patients know about masking?

There's absolutely nothing wrong if a person chooses to wear a mask. I think that certainly in a very crowded environments, very dusty environments, it makes sense to wear a mask. I think that when you're going for a walk in your neighborhood with perhaps a neighbor, it's it becomes a judgment call.

What should I know about preventing infections after transplant once I return home?

Your home does not need to be sterilized, but we do advise people to avoid like, you know, some gardening, any activity that might expose you to mold that's in the soil, like Aspergillus, you know, because you're still even though you're we talked about engraftment you still there's other parts of your immune system that are totally normal.

Yet because the melphalan has affected that. And so you're still susceptible to infections. I advise people to wear a mask because, you know, colds, particularly, you know, even like RSV can be a terrible infection with in someone who's just had a transplant. People can get very sick. They can be in the hospital. So wearing a mask is important.

Just trying to avoid, you know, any situation that could, you know, put you at risk for, for getting sick, you know, so those that's typically what I advise patients. Our transplant center has a whole set of recommendations, which I'm not going to go through in the interest of time, but. And they're going to differ from center to center, what you're going to be told.

But I think any patient getting a transplant should know that they have to be extra cautious. You don't need to sterilize your home, though, but you need to be careful. And, you know, certainly you want to, you know, have some degree of like, of caution and isolation, immediately after a transplant and probably for a few months.