Risk factors and impact of non-Aspergillus mold infections following allogeneic HCT: a CIBMTR infection and immune reconstitution analysis

Risk factors for invasive fungal infections after haematopoietic stem cell transplantation: a systematic review and meta-analysis

BACKGROUND

Invasive fungal infections (IFIs) are common infectious complications after haematopoietic stem cell transplantation (HSCT), seriously threatening the survival of patients.

OBJECTIVES

This systematic review aimed to investigate risk factors associated with IFIs following HSCT.

METHODS

Two authors independently conducted the selection of studies and extraction of data. Risk factors for IFIs, invasive aspergillosis or invasive mould infections and invasive candida infection after HSCT were compiled separately by meta-analysis using RevMan 5.4 and R language 4.1.2.

DATA SOURCES

Pubmed, EMBASE, Web of Science, and the Cochrane Library until April 2023.

STUDY ELIGIBILITY CRITERIA

Case-control or cohort studies that assessed risk factors for IFIs among HSCT recipients were included.

PARTICIPANTS

Patients experiencing HSCT.

TEST/S

None.

REFERENCE STANDARD

The IFIs were defined according to the European Organisation for Research and Treatment of Cancer/Mycosis Study Group (EORTC/MSG) criteria, or a similar definition.

ASSESSMENT OF RISK OF BIAS

A modified version of the Newcastle-Ottawa Scale was used.

METHODS OF DATA SYNTHESIS

A random-effects model with the Mantel-Haenszel method was used to pool results from primary studies.

RESULTS

Out of 1637 studies screened, 51 studies involving 109 155 patients were included, with 45 studies providing adequate data for meta-analysis. Identified risk factors for IFIs included prolonged neutropenia, intensified therapy for graft-versus-host disease (GVHD), previous transplantation, previous proven or probable IFI, acute GVHD ≥ grade II, extensive or severe chronic GVHD, use of anti-thymocyte globulin during transplantation, haploidentical transplantation, high-dose glucocorticoids, Epstein-Barr virus infection, cytomegalovirus infection or reactivation, and lower albumin. Conversely, antifungal prophylaxis emerged as the sole preventive factor. For invasive aspergillosis or invasive mould infections, the top risk factors were extensive or severe chronic GVHD, respiratory viral infection, high-dose glucocorticoids, acute GVHD ≥ grade II, and human leukocyte antigen mismatch. Cord blood transplantation was the sole significant risk factor for invasive candidiasis. However, there was likely a high degree of interdependence among various risk factors.

DISCUSSION

This meta-analysis provides a thorough review of risk factors for IFIs infection after HSCT. The achieved insights can aid in stratifying patients who are at an elevated risk of IFIs and promoting antifungal preventive strategies.

Recent Trends in the Epidemiology of Fungal Infections

The breadth of fungi causing human disease and the spectrum of clinical presentations associated with these infections has widened. Epidemiologic trends display dramatic shifts with expanding geographic ranges, identification of new at-risk groups, increasing prevalence of resistant infections, and emergence of novel multidrug-resistant pathogenic fungi. Certain fungi have been transmitted between patients in clinical settings. Major health events not typically associated with mycoses resulted in larger proportions of the population susceptible to secondary fungal infections. Many health care-related, environmental, and socioeconomic factors have influenced these epidemiologic shifts. This review summarizes updates to clinically significant fungal pathogens in North America.

[Non-aspergillus molds infection after allogeneic stem cell transplantation: clinical analysis of 24 cases and outcomes]

目的

分析异基因造血干细胞移植（allo-HSCT）后非曲霉属丝状真菌病（NAMI）的临床特点及预后。

方法

回顾性分析2010年1月1日至2016年12月31日在北京大学血液病研究所接受allo-HSCT后诊断（确诊或临床诊断）为NAMI的24例患者，总结其临床特点及预后。

结果

24例移植后NAMI患者，男21例（87.5%），女3例（12.5%），中位年龄33（10~66）岁。NAMI中位发生时间为移植后188（2~856）d，10例为确诊，14例为临床诊断；19例（79.2%）发生在肺部，4例（16.7%）发生在中枢神经系统，1例（4.2%）发生在鼻窦；病原菌分布中根霉菌14例（58.3%）、毛霉菌5例（20.8%）、犁头霉菌3例（12.5%），尖端赛多孢子菌2例（8.3%）；临床症状为发热20例（83.3%），头痛4例（16.7%），咯血、腹痛腹泻、抽搐（颅内感染）各2例（8.3%），胸痛1例（4.2%）。在18例根据病原学结果调整抗真菌治疗的患者中，治疗的有效率为38.9%（7/18）。中位随访时间为自NAMI诊断后229（2~2 280）d，2年总生存率为（24.0±14.5）%。

结论

allo-HSCT后非曲霉菌属丝状真菌感染以根霉菌为主，临床表现缺乏特异性，死亡率高。

Patterns of infection and infection-related mortality in patients with steroid-refractory acute graft versus host disease

This study aimed to characterize the incidence, etiology and outcome of infectious episodes in patients with steroid refractory acute GvHD (SR-GvHD). The cohort included 127 adults treated with inolimomab (77%) or etanercept (23%) owing to acute 2-4 SR-GvHD, with a response rate of 43% on day +30 and a 4-year survival of 15%. The 1-year cumulative incidences of bacterial, CMV and invasive fungal infection were 74%, 65% and 14%, respectively. A high rate (37%) of enterococcal infections was observed. Twenty patients (15.7%) developed BK virus-hemorrhagic cystitis and five percent had an EBV reactivation with only one case of PTLD. One-third of long-term survivors developed pneumonia by a community respiratory virus and/or encapsulated bacteria, mostly associated with chronic GvHD. Infections were an important cause of non-relapse mortality, with a 4-year incidence of 46%. In multivariate analysis, use of rituximab in the 6 months before SCT (hazard ratio; HR 4.2; 95% confidence interval; CI 1.1-16.3), severe infection before SR-GvHD onset (HR 5.8; 95% CI 1.3-26.3) and a baseline C-reactive protein >15 UI/mL (HR 2.9; 95% CI 1.1-8.5) were associated with infection-related mortality. High rates of opportunistic infections with remarkable mortality warrant further efforts to optimize long-term outcomes after SR-GvHD.