Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Infection after haematopoietic stem-cell transplantation
Essential points for quick revision.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Rapid infection during immune failure
Neutropenic sepsis, diffuse hypoxaemia, encephalopathy, severe diarrhoea, disseminated rash or shock after HSCT can deteriorate rapidly and may coexist with graft-versus-host disease or treatment toxicity.
Action: Use ABCDE, isolate according to syndrome, obtain peripheral and line cultures plus urgent targeted samples, start the appropriate febrile-neutropenia or severe-infection regimen immediately, and involve the transplant centre, microbiology or virology and critical care without waiting for transfer.
Synopsis
Predict infection from engraftment, graft-versus-host disease and immune recovery, investigate attenuated syndromes early, and integrate antimicrobials, viral surveillance and prophylaxis with transplant care.
Before engraftment, neutropenia, mucositis and central access favour Gram-negative and Gram-positive bloodstream infection, enteric translocation, Candida, HSV and mould disease when neutropenia is prolonged.
From engraftment to about day 100, impaired cellular immunity and acute graft-versus-host disease favour CMV, HHV-6, adenovirus, respiratory viruses, Pneumocystis and Aspergillus.
After day 100, chronic graft-versus-host disease, corticosteroids, hypogammaglobulinaemia and delayed B- and T-cell recovery sustain VZV, Pneumocystis, mould and encapsulated-bacterial risk.
Key red flags
Fever, hypothermia, rigors or any sepsis physiology before neutrophil recovery requires immediate neutropenic-sepsis treatment.
Pre-engraftment fever
Fever, rigors, mucositis, abdominal symptoms or line discomfort during profound neutropenia represents bacterial sepsis until treated, even when examination shows little inflammation.
Investigation priorities
01
Transplant and immune-phase assessmentFirst step
Set the pre-test probability for bacterial, viral, fungal and non-infectious disease before selecting specialised tests.
02
First-line cultures and severity testsFirst line
Recover bacteria or yeast and detect marrow, kidney, liver, coagulation and perfusion abnormalities that change urgent therapy.
Management branches
PRE-ENGRAFTMENTTreat neutropenic infection now
Fever, rigors or clinical deterioration occurs before neutrophil recovery or during renewed profound neutropenia.
Use the emergency neutropenic-sepsis pathway, take paired cultures rapidly and give locally approved antipseudomonal therapy without waiting for imaging or cell counts.
Examine mouth, line, skin and abdomen, avoid rectal instrumentation and arrange urgent CT for abdominal danger signs or pulmonary features.
Key medicines
Immediate empirical antibacterial therapyUse the centre's HSCT febrile-neutropenia regimen at emergency loading doses after rapid cultures, with renal adjustment and resistant-organism modification directed by microbiology.
LetermovirGive 480 mg orally or intravenously once daily, reduced to 240 mg once daily with ciclosporin; start from day 0 to day 28 and continue through day 100, or to day 200 when the licensed high-risk extension is selected.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.