Infection

1. General

Cancer and its treatment affect the ability of a child's immune system to fight infections. It is this property of the disease and its treatment that will require the most work in helping your child to adjust to normal life outside the hospital. The treatment team's goal is to have your child experience normal relationships with other children, which is possible as long as certain precautions are taken.

2. Bacterial Infection

Bacteria can cause serious infections in children with low blood counts. There are bacteria which live in or on our bodies, and which do not usually cause infection, but may infect a child whose blood counts are low. Children with implanted catheters or medical ports run a higher risk of bacterial infections, but these infections can occur in any child on cancer treatment.

If your child develops a fever or other signs of infection while his or her blood counts are low, it may be necessary to use intravenous antibiotics in the hospital to treat the infection safely. Before antibiotics are started, "cultures" will be obtained to try to identify the organism causing the infection. These results may not be known for 48 hours, so antibiotics will be started right away. It can be difficult to identify the source of infection in children with low blood counts, so antibiotics which will cover the most likely and most serious sources of infection are chosen.

Antibiotics will be continued until blood counts have recovered and all signs of infection are gone.

3. Viral Infection

Viruses usually cause relatively minor infections, such as the common cold or influenza, but certain viruses can cause serious infections in the child on cancer treatment. Viruses are very hard to identify and cannot be treated with antibiotics. Minor viral illnesses are allowed to run their course in a child with normal blood counts. Since the source of infection is so hard to determine in a child on cancer treatment, children with low blood counts and signs of infection (such as fever) may be treated with antibiotics even if a viral infection --- rather than a bacterial infection --- is suspected.

A. Chicken Pox

Chicken pox is a common childhood infection caused by the varicella virus. It is usually mild, and serious complications are rare. However, children who are being treated for cancer and have never had chicken pox may develop a more serious infection, which can cause treatment delays, and even life-threatening complications.

The treatment team can take measures to prevent and treat a chicken pox infection at the time of exposure, if they are made aware that the child has been exposed. It is very important, therefore, for you to keep track of whom your child is in contact with, and when your child was exposed to another child with chicken pox. If your child is in school, the treatment team can work with the school nurse to identify when exposure has occurred. You should also ask the parents of your child's playmates to notify you immediately if any of their children develop chicken pox or any suspicious rash.

Even though chicken pox can be a serious illness in children with cancer, measures can be taken to protect them from complications. A medicine called VZIG (Varicella Zoster Immune Globulin) can be given to try to prevent chicken pox from developing. Even if chicken pox does develop, it is often a more mild case than if the VZIG had not been given. This medicine is given as an injection (i.e. "shot"), and is effective only if given within 96 hours (4 days) of exposure. If you find out your child has been exposed, contact the treatment team right away --- even on a weekend --- so that they can decide if VZIG should be used.

If your child develops chicken pox, there is a very effective anti-viral medicine called Acyclovir which can be used to control the infection and reduce the risk of serious complications. It must, however, be given intravenously, in the hospital. The treatment team will also encourage the consumption of fluids, monitor laboratory test results, and provide measures for reducing the itching. Depending on what stage of treatment your child is in, hospitalization will probably be required.

While chicken pox can be a very serious infection in a child on cancer treatment, the treatment team can protect children from complications if they know about exposures and monitor carefully for the development of symptoms. The fear of chicken pox is no longer a reason to keep your child out of school or away from other children, since infection can be prevented or treated. Close communication is the most important means of keeping your child safe and happy in the company of other children.

B. Shingles

Shingles is another type of infection caused by the varicella virus. Shingles occurs in people who have already had chicken pox. It is a re-activation of the chicken pox virus, and can occur in someone whose immune system is affected by cancer or treatment. Your child cannot catch shingles from someone else, but if the child has never had chicken pox and is exposed to someone with shingles, he or she may develop a chicken pox infection. A limited shingles infection which covers only a small part of the body can usually be treated with outpatient therapy, but may require an interruption in cancer treatment.

If your child develops any kind of rash, you should inform the treatment team right away. Symptoms may appear 7 to 21 days after exposure. Usually chicken pox starts with a 24 to 48-hour period of 'flu-like' symptoms, including fever and perhaps vomiting. The rash then appears, with small red spots on the face or head, spreading to the trunk and then to the arms and legs. After a few days the red spots will turn into little blisters that eventually dry up and form crusts. New spots continue to develop for 3 to 5 days, or sometimes longer in a child on treatment. The rash is often very itchy.

Shingles usually occurs as patches of red or blistered spots along a line of skin on the back or chest, but can occur in other parts of the body. It can be very painful, with a deep burning sensation along the nerves affected by the infection. There can also be fever, chills, and 'flu-like' symptoms as the rash develops.

In a child on cancer treatment, the symptoms of varicella infection can be different from the typical appearance, especially if the child has been treated with VZIG*. If your child develops any kind of a rash or any other suspicious symptoms, contact the treatment team immediately, so they can decide if treatment is necessary.

* Varicella Zoster Immune Globulin

4. Opportunistic Infections

There are organisms which do not normally cause infections but which can cause serious infections in people whose immune systems are affected by cancer or treatment. These infections are called opportunistic infections. They include fungal infections, such as thrush or yeast infections, and pneumocystis pneumonia. It is difficult to prevent exposure to these organisms because they are a normal part of the environment we live in, and do not cause infectious symptoms in people with normal immune systems. The treatment team will monitor your child for these opportunistic infections during periods of increased risk, such as when blood counts are low or when intravenous antibiotics are required for long periods. Your child may be put on a medicine called Bactrim or Septra, to prevent pneumocystis pneumonia.

5. AIDS (HIV Infection)

There has been much publicity and concern about Acquired Immune Deficiency Syndrome (AIDS). Because your child has been diagnosed with cancer, you may have questions or fears about your child's risk for developing this infection.

AIDS is caused by infection with a virus called Human Immuno deficiency Virus (HIV). This virus is transmitted by contact with bodily secretions from an infected person. This contact can occur during sexual intercourse (especially certain "high-risk" sexual acts), sharing of contaminated intravenous equipment, or by transfusion of contaminated blood products. The virus can also be transmitted to an infected mother's offspring during pregnancy, delivery, or breast feeding. Infection does not develop from community or household contacts, such as sharing food or playing together at school.

Children with cancer do not run a greater risk of developing AIDS because of their disease or the side effects of treatment. Children who receive transfusions of blood products during the course of their treatment run only a very small risk of contact with undetected viruses in the blood they receive. All blood used for medical purposes is screened for the presence of HIV as well as other viruses, and the risk of infection is minimal. Children receive blood transfusions only when the treatment team feels it is absolutely necessary for them to have one.

It is important that you feel comfortable talking with your treatment team about any concerns which you, your family, or your community might have about blood transfusions and AIDS. The AIDS issue should not affect your child's treatment for cancer, but because of publicity and misunderstandings, fears may arise and cause stress on your family. By talking about these fears and answering your questions, the treatment team hopes to keep this from becoming an additional worry for your family.

6. Helping to Prevent Infection

Because cancer and its treatment affect the immune system's ability to fight infection, your child will be at increased risk of infection for the duration of his or her therapy. Infections will occur, even if you do everything humanly possible to protect your child, so you should never feel guilty or responsible if an infection develops. Other children --- especially brothers and sisters --- should not be made to feel guilty if an infection develops. There are measures you can take to help prevent certain infections from occurring:

1. THOROUGH HAND WASHING is the most important way to prevent infection. Your child should wash his or her hands before meals, after going to the bathroom, and after playing with other children. Anyone who cares for your child (parents, doctors, nurses, friends) should wash their hands before examining, treating or otherwise touching your child.
2. When your child's blood counts are low, keep people who have symptoms of an infection (such as fever, coughing, sneezing, or sore throat) away from your child. People who have any symptoms of an infection but who must be near your child should wear a mask and wash their hands thoroughly.
3. If your child has an implanted catheter (Hickman, Broviac, etc.) or medical port (e.g. Infusaport or Mediport), follow carefully the instructions for changing dressings and care of the device.

Note: Although sub-cutaneous medical ports such as Infusaports do not require maintenance, they must be flushed periodically to keep them clear.

4. When your child's blood counts are low, talk to your treatment team about whether or not your child should be in school. They can work with the school nurse to make your child's going to school as safe as possible.
5. Notify your treatment team immediately if you find signs or symptoms of an infection. Keep a close watch on your child's mouth, rectal area, and areas of injury, such as cuts in the skin, burns, or biopsy sites. Watch for redness, drainage of fluid, heat or an unusual degree of pain at the site of a wound.

Even when reasonable precautions are taken, your child may still develop fevers or infections. This is no one's fault; it is one of the risks of treating your child for cancer. If fever or infections develop, your most important job is to respond quickly by contacting the treatment team for further instructions. Be sure you are familiar with procedures for contacting your treatment team at all times, in case of an emergency.