Infection prophylaxis in lymphoma: PJP, herpes, fungal risk and vaccination

Pneumocystis jirovecii pneumonia prophylaxis, usually co-trimoxazole 480 to 960 mg daily or 960 mg three times a week, is given during and after: R-CHOP and other anthracycline regimens in the elderly or with prolonged steroid exposure; any regimen containing high-dose or prolonged corticosteroid; purine analogues (fludarabine, cladribine, bendamustine); alemtuzumab; CAR-T and bispecific antibodies; idelalisib, duvelisib and copanlisib, where pneumocystis pneumonia and cytomegalovirus reactivation were the toxicities that limited the class. Alternatives for sulphonamide allergy are dapsone, atovaquone or nebulised pentamidine.

Herpes prophylaxis with aciclovir or valaciclovir is standard with bortezomib, with purine analogues, after autologous transplant and with CAR-T. Antifungal prophylaxis is not routine in lymphoma outside transplant and prolonged neutropenia.

Growth factor support. Primary G-CSF prophylaxis is given with dose-dense and intensive regimens (DA-EPOCH-R, CODOX-M/IVAC, escalated BEACOPP, BrECADD) and to patients over 65 receiving R-CHOP, where febrile neutropenia risk exceeds 20 per cent.

Vaccination. Inactivated influenza and COVID-19 vaccines are given but respond poorly during and for six to twelve months after anti-CD20 treatment; live vaccines are contraindicated. Pneumococcal, Haemophilus influenzae type b and meningococcal vaccination is given before a planned splenectomy for splenic marginal zone lymphoma, and lifelong penicillin prophylaxis follows it. Household contacts should be vaccinated.