EBMT 2026 | Mitigating and managing key infections that patients are at risk of following CAR-T

That’s a huge subject. I feel like we tend to think about infection risk in separate phases, like the first four weeks is kind of the early stage where we see lots of infections. During this period we have patients who have severe neutropenia, they’re experiencing all the immune toxicities, they are getting immunosuppression for these toxicities so we tend to see the highest incidence of infection, and these are up to two-thirds bacterial causes because these patients are in the hospital they’re neutropenic. We do see some herpes virus reactivations during these first four weeks, and particularly cytomegalovirus, since HSV and VZV now with prophylaxis are prevented. And invasive fungal infection remains relatively infrequent. When it occurs, it can be devastating, but at least for now it’s rare. 

When it comes to prevention, which is extremely important, we do not have a consensus. There is this great guideline by ASTCT, and we are currently working on the guideline by the ESOT. And I know there’s also work by ESCMID, but so far we don’t have a lot of high evidence because we do not have randomized trials in infection prevention. So this is very largely extrapolated from allogeneic stem cell transplants and from expert opinion. So I think that you know the different strategies that are implemented in different centers it would be hard to summarize right now but I think that we are all in agreement that we should be preventing HSV and VZV when it comes to viral prevention with valaciclovir or acyclovir. We do give prophylaxis for pneumocystis jirovecii. In some centers, we do give fluconazole to prevent yeast. And in some other centers, we even may step up to posaconazole to prevent mold. And when it comes to bacteria, I come from a center where we do not give fluoroquinolone prophylaxis. I know that out there, there are lots of different practices when it comes to that. But for sure, we should be treating the febrile neutropenia when it occurs. So for the early period, I think I didn’t miss anything. Oh, of course, the cytomegalovirus, which we could be monitoring for, but I think that we still are in lack of data regarding what the actual clinical impact is to see whether we should be treating when we detect or even if we should be preventing. And then on the long run, of course, we should not be forgetting about vaccination and immunoglobulin replacement treatments, but these are mostly for the management of the long-term risk for infection.

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