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the immunocompromised patient in the ED

Introduction

the immunocompromised patient is a high risk patient presenting to ED
they are at high risk of severe sepsis / septicaemia, atypical presentations, and rapid progression of surgical emergencies such as diverticulitis as well as a higher risk of acquiring infections in the hospital environment and the potential need for barrier nursing
these patients are also at higher risk of neuroinvasive disease in arbovirus infections
the most common patients are those on corticosteroids, immunosuppressants or on chemotherapy for cancers

Haematologic neoplasms requiring chemotherapy: leukemias, lymphomas, myelodysplastic syndromes
Post-transplant:
- solid organ such as renal transplant, liver transplant, heart/lung transplant (on immunosuppressive therapy)
- haematopoietic stem cell transplant (within 24 months or on treatment for GVHD)
Immunocompromised due to primary or acquired immunodeficiency (including HIV infection)
Current chemotherapy (within past 2 weeks) or radiotherapy
- CAR T-cell therapy
- anti-CD20 antibody (rituximab, ofatumumab, obinutuzumab)
- targeted therapies such as BTK inhibitors, venetoclax
- anti-CD38 (daratumumab)
- anti-BCMA bi-specific antibody
High-dose corticosteroids (≥20 mg of prednisone per day, or equivalent) for ≥14 days
All biologics and most disease-modifying anti-rheumatic drugs (DMARDs) as defined as follows:
- Azathioprine >3.0 mg/kg/day
- 6-Mercaptopurine >1.5 mg/kg/day
- Methotrexate >0.4 mg/kg/week
- Prednisone >20 mg/day. If <14 days treatment, until treatment ceased
- Tacrolimus (any dose)
- Cyclosporine (any dose)
- Cyclophosphamide (any dose)
- Mycophenolate (any dose)
- Combination (multiple) DMARDs irrespective of dose
Primary severe combined immunodeficiency syndromes
HIV with CD4 < 50