Meningitis Due to Multiple-Resistant Penicillin- and Cefotaxime-Intermediate Streptococcus pneumoniae in a German Child after Bone Marrow Transplantation

Infectious complications of stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) is an accepted treatment for a variety of hematologic malignancies. The profound immunosuppression these patients experience adversely affects their risk of infection. This risk is much higher than in the general population and requires aggressive diagnostic and therapeutic interventions. The chapter will outline the major infections after HSCT.

Treatment and prevention strategies to combat pediatric pneumococcal meningitis

Pneumococcal meningitis is a severe, life-threatening infection of the nervous system affecting infants, children and adults alike. The incidence of pneumococcal meningitis in infants and children less than 2 years of age in Europe is approximately 10 out of 100,000 per year, rising to approximately 148 out of 100,000 per year in Gambian infants. The use of highly sensitive tests such as PCR may increase the likelihood of detecting the infection by 20% or more. Epidemics of serotype 1 pneumococcal meningitis in northern Ghana, have had many of the characteristics of meningococcal meningitis epidemics. Neurologic sequelae may occur in 28-63% of cases, and serotype 3 is associated with a 2.54 relative risk of death. The pathogenic process can be divided into invasion, inflammatory pathways, bacterial toxicity and damage; pneumolysin being particularly associated with apoptosis. In the future, neuroprotection may be achieved, targeting this process at all these levels. Therapeutic guidelines have been published by the Infectious Diseases Society of America. Standard empiric therapy, in those aged greater than or equal to 1 month, is a third-generation cephalosporin plus vancomycin. There is insufficient evidence relating to the use or otherwise of corticosteroids in pneumococcal meningitis to make a firm recommendation. The advent of a pneumococcal conjugate vaccine is the most powerful tool available for the prevention of pneumococcal meningitis in all parts of the world.

Streptococcus pneumoniae infections in 47 hematopoietic stem cell transplantation recipients: clinical characteristics of infections and vaccine-breakthrough infections, 1989-2005

Streptococcus pneumoniae infections can cause serious systemic disease in patients following hematopoietic stem cell transplantation (HSCT), and the response to pneumococcal vaccine is inadequate in most HSCT recipients. We evaluated the clinical spectrum of pneumococcal disease and vaccine-breakthrough infections in HSCT recipients at our cancer center in a retrospective analysis of all consecutive episodes of S. pneumoniae infection from 1989 through 2005. During the study period, 7888 patients underwent HSCT at our center; we identified 47 HSCT recipients with 54 S. pneumoniae infections. The overall incidence of S. pneumoniae infection was 7 per 1000 HSCTs. The incidence was higher in recipients of allogeneic grafts than in recipients of autologous grafts (9 vs. 5 per 1000 HSCTs, respectively; p <or= 0.012). Thirty-two of the 47 patients (68%) had leukemia or lymphoma; 24 patients (51%) had a malignancy that was in complete remission. Seventeen patients (36%) had graft-versus-host disease, which was chronic in 16. The 54 episodes of S. pneumoniae infection occurred 433 +/- 669 days after HSCT; 5 patients (11%) had multiple episodes. Four episodes of S. pneumoniae infection occurred within 100 days following transplantation (45 +/- 49 d); 2 of these were during the pre-engraftment period and 3 were nosocomial infections. All 50 late post-transplant episodes (93%), which occurred 473 +/- 671 days following transplantation, were community-acquired infections (p < 0.00016). Thirty-three episodes (61%) presented as bacteremic pneumonia, 10 (19%) as pneumonia, and 8 (15%) as uncomplicated S. pneumoniae bacteremia alone. Logistic regression analysis showed that patients receiving systemic corticosteroids had increased risk for bacteremic pneumonia (odds ratio [OR], 11.7; 95% confidence intervals [CI], 1.371-99.280; p <or= 0.025). Patients with lymphoma (OR, 6.101; 95% CI, 1.106-33.640; p <or= 0.04) were more likely to develop pneumonia alone. In 27 episodes (93%) among 29 in which S. pneumoniae susceptibility testing was performed, the patients received concordant antimicrobials. Among the 6 patients (13%) who died of S. pneumoniae infection, 4 had S. pneumoniae bacteremic pneumonia and only 1 had chronic GVHD. Admission to a critical care unit at the onset of infection (OR, 15.5; 95% CI, 2.116-113.541; p <or= 0.007) and each unit increase in APACHE II score increase the probability of death (OR, 1.9; 95% CI, 1.181-3.054; p <or= 0.008). All 5 (11%) patients who developed vaccine-breakthrough S. pneumoniae infection (546 +/- 732 d following vaccination) had pneumonia, and in 4 patients concurrent bacteremia also occurred. A serious S. pneumoniae infection in HSCT recipients occurred more commonly in patients with lymphoma and patients receiving high-dose systemic corticosteroid therapy. It is noteworthy that there were no cases of extrapulmonary organ infection in HSCT recipients who presented with S. pneumoniae infection at our institution.