Acute bacterial endocarditis during granulocytopenia in an allogenic marrow transplant recipient

Infective endocarditis is rare in patients with hematologic malignancy and neutropenia

BACKGROUND

Infective endocarditis (IE) is a serious complication of bloodstream infections (BSIs) that occurs at variable rates depending on the pathogen and clinical setting. There is a paucity of data describing the risk of IE in patients with hematologic malignancy who develop bacteremia while neutropenic.

METHODS

Adult patients on the hematology ward from January 2018 to December 2020 with hematologic malignancy and bacteremia were evaluated retrospectively for endocarditis by applying the 2023 Duke-ISCVID criteria. Charts of possible cases were evaluated 90 days after the initial BSI for new infectious complications that could indicate missed IE. Descriptive statistics compared patients admitted for hematopoietic stem cell transplantation (HSCT) to those admitted for alternative reasons (non-HSCT).

RESULTS

Among the 1005 positive blood cultures initially identified, there were 66 episodes in 65 patients with hematologic malignancy and at least grade 3 neutropenia for a mean duration of 11.4 days during their admission. Transthoracic echocardiography (TTE) was performed in 34.8% of BSIs, and transesophageal echocardiography (TEE) in 6.1%. There were no new infectious complications in possible cases 90 days after their initial BSI. No cases of endocarditis were identified.

CONCLUSIONS

Endocarditis is rare amongst patients with hematologic malignancy, bacteremia, and neutropenia, and no cases were identified in this cohort. The use of routine TTE in this setting seems unwarranted, and the addition of TEE is unlikely to improve patient-centered outcomes.

Establishment of a Risk Prediction Model for Pulmonary Infection in Patients with Advanced Cancer

Objective

Based on clinical data, the risk prediction model of pulmonary infection in patients with advanced cancer was established to predict the risk of pulmonary infection in patients with advanced cancer, and intervention measures were given in advance.

Methods

The clinical data of 2755 patients were divided into infection group and control group according to whether they were complicated with lung infection. 1609 patients' data from January 2016 to December 2018 served as the training set, and 1166 patients' data from January 2019 to December 2020 served as the testing set. Demographics, whether the primary cancer was lung cancer, lung metastasis, the pathological classification of lung cancer patients, the number of metastases, history of surgery, history of chemotherapy, history of radiotherapy, history of central venous catheterization, history of hypertension, diabetes, and whether with myelosuppression were recorded. The presence of concurrent pulmonary infection was recorded and defined as the primary outcome variable. Stepwise forward algorithms were applied to informative predictors based on Akaike's information criterion. Multivariable logistic regression analysis was used to develop the nomogram. An independent testing dataset was used to validate the nomogram. Receiver-operating characteristic curves and the Hosmer-Lemeshow test were used to assess model performance.

Results

The sample included 2755 patients with advanced cancer. An independently validated dataset included 1166 patients with advanced cancer. In the training dataset, gender, age, lung cancer as primary cancer, the pathological classification of lung cancer patients, history of chemotherapy, history of radiation therapy, history of surgery, the number of metastases, presence of central venous catheterization, and myelosuppression were identified as predictors and assembled into the nomogram. The area under curve demonstrated adequate discrimination in the validation dataset (0.77; 95% confidence interval, 0.74 to 0.79). The nomogram was well calibrated, with a Hosmer-Lemeshow χ 2 statistic of 12.4 (P = 0.26) in the testing dataset.

Conclusions

The present study has proposed an effective nomogram with potential application in facilitating the individualized prediction of risk of pulmonary infection in patients with advanced cancer.

Critical care considerations of hematopoietic stem cell transplantation

OBJECTIVE

To review the available clinical data on the critical care complications of hematopoietic stem cell transplantation (HSCT).

DATA SOURCE

The MEDLINE database and references from the identified articles related to the critical care in HSCT.

CONCLUSION

HSCT is an important treatment for a variety of malignant and nonmalignant conditions. The procedure is, however, limited by significant complications that may involve every organ of the body. Up to 40% of HSCT recipients are admitted to the intensive care unit as a result of severe complications related to the transplantation. The outcome of those critically ill patients has been traditionally poor. However, recent advances in the transplantation procedure, diagnostic studies, antimicrobial prophylaxis and therapy, and intensive care unit care have improved the outcome of these patients. The increasing number of HSCTs performed annually, the unique complications that develop in these patients, and the improvement in the intensive care unit outcome make knowledge about the critical care aspect of HSCT an essential part of the current practice of critical care medicine.

Characteristics and outcome of patients developing endocarditis following hematopoietic stem cell transplantation

Endocarditis is an uncommon complication of hematopoietic stem cell transplantation (HSCT). A retrospective review of 1547 patients who underwent HSCT in Vancouver between January 1986 and December 2001 was performed. In all, 20 cases of endocarditis were identified (1.3% of all patients) with nine patients having received cryopreserved autologous stem cells, six stem cells from a histocompatible sibling and five patients stem cells from an unrelated donor. Five patients had endocarditis diagnosed while alive, a median of 6 months post-HSCT, by transthoracic (four patients) or transesophageal (one patient) echocardiography. The remaining 15 cases of endocarditis were only identified post mortem. The mitral valve was the most frequently involved (10 patients) followed by the aortic valve (six patients); multivalvular disease was noted in five patients. Of the 11 affected allogeneic HSCT patients, 10 had previously developed acute graft-versus-host disease (GVHD). Causative organisms were identified in 11 patients, while nine additional cases were felt to be thrombotic in origin. Of the 20 patients, 19 died with the sole survivor alive 10 years following an aortic valve replacement. Endocarditis is an uncommon complication of HSCT usually involving the cardiac valves on the left side of the heart and is associated with a high mortality rate.