Patterns of recovery phase infection after autologous blood progenitor cell transplantation in patients with malignancies. The Gruppo Italiano di Studio per la Manipolazione Cellulare in Ematologia

A study of incidence and characteristics of infections in 476 patients from a single center undergoing autologous blood stem cell transplantation

Infectious complications are a major cause of morbidity and mortality in patients who undergo autologous stem cell transplantation (ASCT). We examined 476 patients with hematologic malignancies (401) or solid tumors (75) who underwent ASCT between February 1990 and May 2005. Anti-infectious prophylaxis consisted of different combinations of ciprofloxacin, cotrimoxazole, fluconazole, aerosolized amphotericin B, acyclovir, and intravenous immunoglobulins. Overall, 454 patients (95%) developed fever in the first 60 days after ASCT. In the majority of patients, initial antibiotic therapy consisted of broad-spectrum beta-lactamic with or without amikacin. A glycopeptide was administered as initial therapy in 86 cases. Overall, there were 132 (29%) clinically documented infections (37 pneumonias), 79 (17%) microbiologically documented infections (65 bacteremias), and 243 (54%) fevers of unknown origin. Coagulase-negative staphylococci (18, 25%) and E coli (18, 25%) were the organisms most frequently isolated. The pattern of infection did not change throughout the study except for a significantly higher incidence of bacteremia due to gram-positive bacteria in the first 5 years of the study. Infection-related mortality was 5% (21 cases), with pneumonia the most frequent cause of death. ASCT should be considered a low-risk procedure, although new therapeutic approaches for patients developing severe respiratory infections are still needed.

Long-term antifungal prophylaxis in high-risk hematopoietic stem cell transplant recipients

The risks for invasive fungal infections, particularly mould infections such as invasive aspergillosis, among hematopoietic stem cell transplant (HSCT) recipients are linked to the duration and severity of myelosuppression and immunosuppression. Strategies to prevent invasive fungal infections have focused primarily on the use of orally administered azole antifungal agents during the neutropenic period rather than on the more prolonged post-engraftment period. The major limitations of these studies included the heterogeneity among the subjects studied for fungal infection risk factors, the agents administered, the dosing, and duration of prophylaxis. More recent studies have attempted to examine the efficacy of antifungal prophylaxis strategies among allogeneic HSCT recipients to day 100 and beyond. It is clear that a variety of products have efficacy in preventing invasive candidiasis, including imidazole and triazole antifungals, low-dose amphotericin B, and the echinocandin, micafungin; however, only the extended spectrum azole, itraconazole, has been shown to impact the incidence of proven invasive aspergillosis. Other extended spectrum azole antifungal agents, voriconazole and posaconazole, are being studied as long-term prophylaxis in high-risk HSCT recipients. While clinical trials have suggested that a duration of prophylaxis against moulds of six months or more may be required, it remains unclear if this is required in all cases. The prophylactic efficacy over time may be linked to the degree of immunosuppression as measured by markers such as the numbers of circulating CD4 T lymphocytes. Concerns about selection for resistant moulds among long-term recipients of these drugs are emerging. The cumulative experience to date suggests that long-term antifungal chemoprophylaxis is feasible and effective when applied in defined circumstances. The concerns about treatment-related toxicities, resistance, and costs are valid.

Invasive fungal infections in autologous stem cell transplant recipients: a nation-wide study of 1188 transplanted patients

Based on small single-centre series, the risk of invasive fungal infections (IFI) has been considered small in autologous stem cell transplant (ASCT) recipients.

PURPOSE

To analyse epidemiological and clinical features of (IFI) among ASCT recipients in Finland 1990-2001.

PATIENTS

During the study period, 1188 adult patients received high-dose therapy supported by ASCT in six centres. Altogether, 1112 patients (94%) received blood progenitor cells. The graft was CD34+ selected in 261 patients (22%). The major diagnostic groups were non-Hodgkin's lymphoma (n = 417), multiple myeloma (n = 395), breast cancer (n = 132) and Hodgkin's lymphoma (n = 53).

RESULTS

Eighteen patients (1.5%) with IFI were identified. The incidence of proven or probable invasive aspergillosis was 0.8%, followed by candidaemia with an incidence of 0.3%. The median time to the diagnosis of IFI was 35 d (6-162) from the progenitor cell infusion. In fourteen patients (78%) IFI was diagnosed during lifetime and they were treated with antifungal therapy for a median of 50 d. Nine patients (64%) were cured.

CONCLUSIONS

IFI appears to be a rare event after ASCT and Aspergillus infections seem to be predominant. These epidemiological features have an impact in planning prophylactic and empirical antifungal strategies in ASCT recipients.

Risk of neutropenic fever and early infectious complications after autologous peripheral blood stem cell transplantation for malignant diseases

Autologous peripheral blood stem cell transplantation (auto-PBSCT) has facilitated high-dose chemotherapy for the treatment of various types of malignancy, but the factors affecting the treatment outcome have not been well defined. We evaluated patients who underwent auto-PBSCT (46 patients with hematological malignancies and 39 with solid tumors) to elucidate the risks of background factors, including age, in association with infectious complications. In contrast to former reports, faster engraftment did not influence the incidence of documented infection or neutropenic fever, whereas high age (age > or = 50 years old) and delayed platelet recovery (> or = 18 days) were demonstrated to be positively involved. The odds ratio (OR) for documented infection in elderly patients was 4.94 (95% confidence interval, 1.22-15.8). Another risk factor of infection was the HD-ICE regimen (ifosfamide, carboplatin, etoposide) given to patients with solid tumors (OR, 8.00; 95% confidence interval, 1.61-39.7). In conclusion, we found that elderly patients and patients on the HD-ICE regimen have a higher risk of infectious complications even after auto-PBSCT. Although the clinical indications for auto-PBSCT can be extended to elderly patients, thorough precautions should be taken against infectious complications during the pre-engraftment phase.

Catheter-related candidemia caused by Candida lipolytica in a patient receiving allogeneic bone marrow transplantation

Candida lipolytica was recovered from the blood and the central venous catheter in a patient receiving allogeneic bone marrow transplantation. Two C. lipolytica strains from different geographical areas and the ATCC 9773 strain of C. lipolytica were used as controls. C. lipolytica was identified by standard methods. MICs indicated antifungal susceptibilities to amphotericin B, fluconazole, and itraconazole for all strains. In vitro testing and scanning electron microscopy showed that C. lipolytica was capable of producing large amounts of viscid slime material in glucose-containing solution, likely responsible for the ability of the yeast to adhere to catheter surfaces. Restriction fragment length polymorphisms revealed an identical profile for all clinical isolates, unrelated to those observed for the control strains. This finding suggested the absence of microevolutionary changes in the population of the infecting strain, despite the length of the sepsis and the potential selective pressure of amphotericin B, which had been administered to the patient for about 20 days. The genomic differences that emerged between the isolates and the control strains were indicative of a certain degree of genetic diversity between C. lipolytica isolates from different geographical areas.

Infectious complications after high-dose chemotherapy and autologous stem cell transplantation: comparison between patients with lymphoma or multiple myeloma and patients with solid tumors

From November 1994 to May 1998, 117 patients (66 with solid tumor, 36 with lymphoma, 14 with multiple myeloma, one with acute leukemia) underwent 178 cycles of high-dose chemotherapy and autologous stem cell transplantation (ASCT) at our institution. We retrospectively analyzed the infectious complications that occurred after ASCT. Median duration of neutropenia (granulocyte count <0.5 x 10(9)/l ) was 8 days, the overall incidence of fever requiring antimicrobial treatment was 63%. 35.4% of patients had fever of unknown orign (FUO), whereas primary bacteremia occurred in 21.3%, pneumonia in 3.4% and severe skin infection in 1.1% of patients. Invasive fungal infections occurred in three, and enterocolitis in one patient. Infection was fatal in three patients (2.6%), in each case due to septic shock. The most frequently isolated pathogens were Gram-positive cocci. Median time to defervescence with antimicrobial therapy was 4 days (6 days in patients with bacteremia or other severe infection, and 3 days in patients with FUO). First-line antimicrobial therapy was successful in 65% of patients with FUO and 30.6% of patients with documented infections. With respect to the incidence, type and clinical course of infection, no significant differences between patients with lymphoma or multiple myeloma and those with solid tumors were detected.

Low infectious morbidity after intensive chemotherapy and autologous peripheral blood progenitor cell transplantation in the outpatient setting for women with breast cancer

Autologous peripheral blood progenitor cell (PBPC) transplantation is increasingly employed in the outpatient setting, yet data on early complications following PBPC transplantation are scant. We evaluated 105 women with high-risk primary or metastatic breast cancer who were treated at a single institution during 1996--1997. The mean duration of neutropenia (absolute neutrophil count, <500 cells/mm(3)) was 7.5 days. Twenty-nine percent of women remained afebrile throughout the neutropenic period. Of the remaining 71%, most (64 of 75) had fever of unknown origin. Infections, mostly of mild severity, occurred in 34% of women; these infections included bacteremia due to gram-positive organisms, catheter site infection, cellulitis, pneumonia, oral candidiasis, herpes simplex virus infection, and vaginitis. Fifty percent of PBPC transplant recipients required hospital admission, usually because of persistent fever; the mean duration of hospitalization was 3 days. No deaths or serious adverse events occurred. Such reduced infectious morbidity may be a consequence of minimal oral and/or gastrointestinal mucositis associated with the conditioning regimen and broad-spectrum antimicrobial prophylaxis used for this patient population.

Early infections after autologous transplantation for haematological malignancies

The purpose of this study was to evaluate the early infectious complications following autologous transplantation in haematological patients. Sixty-one patients who underwent either autologous bone marrow (BM; 28 patients) or peripheral blood stem cell (PBSC; 33 patients) transplantation for haematological malignancies were reviewed retrospectively. Engraftment happened significantly faster and the length of hospital stay was shorter in the PBSC group compared with the BM group. All patients in the study developed fever and all but two experienced temperatures > or = 38.5 degrees C. Overall, 57 patients had signs of oral mucositis, 23 with ulceration. Twenty patients had bacteraemia, 12 developed pneumonia, 6 systemic fungal infection. No major differences were found between the two groups in distribution or incidence of infections. This study indicates that the use of peripheral blood stem cells results in faster engraftment and shorter hospital stay, whereas the effect on the incidence of early infections seems to be unaffected.