What are the guidelines for preventing infections in a patient with glomerulonephritis (inflammation of the glomeruli) and impaired renal function, starting immunosuppressants, with a history of recurrent infections or underlying health conditions?

Infection Prevention Guidelines for Glomerulonephritis Patients Starting Immunosuppression

Patients with glomerulonephritis and impaired renal function who are starting immunosuppressive therapy require comprehensive infection prophylaxis, including pneumococcal vaccination, influenza vaccination for patient and household contacts, prophylactic trimethoprim-sulfamethoxazole for those receiving high-dose prednisone or other immunosuppressants (rituximab, cyclophosphamide), and pre-treatment screening for latent infections including tuberculosis, hepatitis B, hepatitis C, HIV, and syphilis. 1

Pre-Immunosuppression Screening

Before initiating any immunosuppressive therapy, the following screening is essential:

• Screen for tuberculosis (TB) using tuberculin skin testing or interferon-gamma release assays in all patients, particularly those with risk factors or from endemic areas 1, 2
• Test for hepatitis B virus (HBV), hepatitis C virus (HCV), HIV, and syphilis in clinically appropriate patients to identify latent infections that could reactivate 1, 2
• Review and update vaccination status before starting immunosuppression, as vaccine efficacy decreases once immunosuppression begins 2, 3

Vaccination Requirements

Pneumococcal Vaccination

• Administer pneumococcal vaccine to all patients with nephrotic syndrome and/or chronic kidney disease before starting immunosuppression 1, 2, 3

Influenza Vaccination

• Ensure both the patient and all household contacts receive annual influenza vaccine to reduce transmission risk 1, 2, 3

Herpes Zoster Vaccination

• Provide herpes zoster vaccination (Shingrix) to reduce risk of reactivation during immunosuppression 2, 3

Meningococcal Vaccination

• Administer meningococcal vaccine specifically in patients with complement deficiencies or those treated with complement inhibitors 1

Antimicrobial Prophylaxis

Trimethoprim-Sulfamethoxazole (TMP-SMX)

Prophylactic trimethoprim-sulfamethoxazole should be strongly considered in patients receiving high-dose prednisone or other potent immunosuppressive agents (rituximab, cyclophosphamide). 1, 2, 3

• This recommendation is particularly critical given research showing that Pneumocystis jiroveci pneumonia (PJP) occurs in glomerulonephritis patients receiving immunosuppressants, with average onset at 2.4 months after initiation 4
• Risk factors for PJP infection include: high serum creatinine at immunosuppressant initiation, low hemoglobin, low absolute lymphocyte count, high chronicity indices on kidney pathology, and persistent lymphocytopenia during treatment 4
• For patients with ANCA vasculitis and upper respiratory tract disease, trimethoprim-sulfamethoxazole serves dual purposes as both infection prophylaxis and adjunctive maintenance therapy 1

Special Considerations for High-Risk Patients

Patients with Recurrent Infections

For patients with a history of recurrent infections:

• Monitor absolute lymphocyte count closely during immunosuppression, as persistent lymphocytopenia is a predictor of opportunistic infections like PJP 4
• Consider dose reduction of immunosuppressants in patients with persistent lymphocytopenia or high chronicity of kidney disease 4
• Maintain heightened vigilance for infection symptoms, particularly respiratory infections, during the first 3 months after immunosuppression initiation when PJP risk peaks 4

Patients with Impaired Renal Function

• Adjust antimicrobial prophylaxis doses according to the degree of kidney function impairment 1
• Patients with elevated serum creatinine at immunosuppressant initiation have higher infection risk and require more aggressive prophylaxis 4

Monitoring During Immunosuppression

• Assess for signs of infection regularly, including fever, respiratory symptoms, and unexplained clinical deterioration 4
• Monitor therapeutic drug levels of immunosuppressants where clinically indicated to avoid excessive immunosuppression 2, 3
• Maintain awareness that immunosuppressive regimens themselves (daily dose, duration, cumulative dose) may not differ between patients who develop infections versus those who don't—rather, baseline patient factors predict infection risk 4

Critical Pitfalls to Avoid

• Do not delay prophylaxis until after infections occur; prevention must begin before or concurrent with immunosuppression initiation 1, 2
• Do not overlook household contacts for influenza vaccination, as they represent a significant transmission source 1, 2
• Do not assume all patients require the same prophylaxis intensity—tailor based on specific immunosuppressive regimen (high-dose prednisone, cyclophosphamide, and rituximab carry highest risk) 1
• Do not continue full-dose immunosuppression in patients developing severe infections; temporary dose reduction or discontinuation may be necessary 4