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Plate M, van Besien K. Is less more? Viewpoint on empiric vancomycin therapy of fever and neutropenia after allogeneic stem cell transplantation. Leuk Lymphoma 2020; 62:255-256. [PMID: 33356693 DOI: 10.1080/10428194.2020.1864357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Markus Plate
- Weill Cornell Medicine, Division of Infectious Diseases, Transplant-Oncology Infectious Diseases Program, New York, NY, USA
| | - Koen van Besien
- Weill Cornell Medicine, Division of Hematology and Medical Oncology, Transplant and Cell Therapy Program, New York, NY, USA
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2
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Peseski AM, McClean M, Green SD, Beeler C, Konig H. Management of fever and neutropenia in the adult patient with acute myeloid leukemia. Expert Rev Anti Infect Ther 2020; 19:359-378. [PMID: 32892669 DOI: 10.1080/14787210.2020.1820863] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Febrile neutropenia represents one of the most common treatment-associated complications in the management of acute myeloid leukemia (AML) and is considered an oncologic emergency. Rapid and detailed workup as well as the initiation of empiric broad-spectrum antibiotic therapy are critical to avoid sepsis and to reduce mortality. Although a definitive source of infection is frequently not identified, the severely immunosuppressed status of the AML patient undergoing cytotoxic therapy results in a high risk for a wide array of bacterial, fungal, and viral etiologies. AREAS COVERED The authors herein review the diagnostic and therapeutic approach to the neutropenic leukemia patient based on the current knowledge. Special consideration is given to the rapidly changing therapeutic landscape in AML, creating new challenges in the management of infectious complications. EXPERT OPINION Multidrug-resistant organisms pose a major challenge in the management of neutropenic fever patients with hematologic malignancies - including AML. Future directions to improve outcomes demand innovative treatment approaches as well as advances in biomarker research to facilitate diagnosis and disease monitoring. Recent achievements in AML-targeted therapy led to an increased incidence of differentiation syndrome, a potentially life-threatening side effect that frequently resembles clinical infection and requires prompt recognition and aggressive intervention.
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Affiliation(s)
- Andrew M Peseski
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mitchell McClean
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Steven D Green
- Melvin and Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cole Beeler
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Heiko Konig
- Melvin and Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, USA
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3
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Febrile Neutropenia in Acute Leukemia. Epidemiology, Etiology, Pathophysiology and Treatment. Mediterr J Hematol Infect Dis 2020; 12:e2020009. [PMID: 31934319 PMCID: PMC6951355 DOI: 10.4084/mjhid.2020.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/17/2019] [Indexed: 12/11/2022] Open
Abstract
Acute leukemias are a group of aggressive malignant diseases associated with a high degree of morbidity and mortality. An important cause of both the latter is infectious complications. Patients with acute leukemia are highly susceptible to infectious diseases due to factors related to the disease itself, factors attributed to treatment, and specific individual risk factors in each patient. Patients with chemotherapy-induced neutropenia are at particularly high risk, and microbiological agents include viral, bacterial, and fungal agents. The etiology is often unknown in infectious complications, although adequate patient evaluation and sampling have diagnostic, prognostic and treatment-related consequences. Bacterial infections include a wide range of potential microbes, both Gram-negative and Gram-positive species, while fungal infections include both mold and yeast. A recurring problem is increasing resistance to antimicrobial agents, and in particular, this applies to extended-spectrum beta-lactamase resistance (ESBL), Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE) and even carbapenemase-producing Enterobacteriaceae (CPE). International guidelines for the treatment of sepsis in leukemia patients include the use of broad-spectrum Pseudomonas-acting antibiotics. However, one should implant the knowledge of local microbiological epidemiology and resistance conditions in treatment decisions. In this review, we discuss infectious diseases in acute leukemia with a major focus on febrile neutropenia and sepsis, and we problematize the diagnostic, prognostic, and therapeutic aspects of infectious complications in this patient group. Meticulously and thorough clinical and radiological examination combined with adequate microbiology samples are cornerstones of the examination. Diagnostic and prognostic evaluation includes patient review according to the multinational association for supportive care in cancer (MASCC) and sequential organ failure assessment (SOFA) scoring system. Antimicrobial treatments for important etiological agents are presented. The main challenge for reducing the spread of resistant microbes is to avoid unnecessary antibiotic treatment, but without giving to narrow treatment to the febrile neutropenic patient that reduce the prognosis.
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4
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Wardill HR, Secombe KR, Bryant RV, Hazenberg MD, Costello SP. Adjunctive fecal microbiota transplantation in supportive oncology: Emerging indications and considerations in immunocompromised patients. EBioMedicine 2019; 44:730-740. [PMID: 30940601 PMCID: PMC6603490 DOI: 10.1016/j.ebiom.2019.03.070] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/25/2019] [Accepted: 03/25/2019] [Indexed: 02/07/2023] Open
Abstract
FMT has gained enormous momentum in the treatment of acute inflammatory and infectious diseases. Despite an encouraging safety profile, FMT has been met with caution in the oncological setting due to perceived infectious risks in immunocompromised patients. Theoretical risks aside, the application of FMT in oncology may stand to benefit patients, via modulation of treatment efficacy and the mitigation of treatment complications. Here, we summarize most recent safety data of FMT in immunocompromised cohorts, including people with cancer, highlighting that FMT may actually provide protection against bacterial translocation via introduction of a diverse microbiome and restoration of epithelial defenses. We also discuss the emerging translational applications of FMT within supportive oncology, including the prevention and treatment of graft vs. host disease and sepsis, treatment of immunotherapy-induced colitis and restoration of the gut microbiome in survivors of childhood cancer.
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Affiliation(s)
- H R Wardill
- Adelaide Medical School, University of Adelaide, South Australia, Australia; Beatrix Children's Hospital, Department of Pediatric Oncology, University Medical Centre Groningen, Groningen, the Netherlands.
| | - K R Secombe
- Adelaide Medical School, University of Adelaide, South Australia, Australia
| | - R V Bryant
- Adelaide Medical School, University of Adelaide, South Australia, Australia; IBD Service, Department of Gastroenterology, The Queen Elizabeth Hospital, South Australia, Australia
| | - M D Hazenberg
- Department of Hematology, Amsterdam University Medical Centre, Location AMC, Cancer Center Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
| | - S P Costello
- Adelaide Medical School, University of Adelaide, South Australia, Australia; IBD Service, Department of Gastroenterology, The Queen Elizabeth Hospital, South Australia, Australia
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5
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Kamboj M, Cohen N, Huang YT, Kerpelev M, Jakubowski A, Sepkowitz KA, Papanicolaou GA, Seo SK. Impact of Empiric Treatment for Vancomycin-Resistant Enterococcus in Colonized Patients Early after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2018; 25:594-598. [PMID: 30448456 DOI: 10.1016/j.bbmt.2018.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 11/08/2018] [Indexed: 01/07/2023]
Abstract
In recent years, vancomycin-resistant Enterococcus (VRE) colonization is being increasingly encountered in transplant recipients, and VRE has become one of the leading causes of bacteremia early after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Data are sparse on the effect of empiric VRE therapy for febrile, neutropenic allo-HSCT recipients colonized with VRE. All allo-HSCT recipients aged ≥18years who developed VRE bacteremia (VREB) between 2005 and 2014 were identified and categorized as to whether they received empiric or directed VRE therapy. There were 434 (33%) VRE-colonized and 872 (67%) non-VRE-colonized patients during the study period, and 172 of the 434 (40%) VRE-colonized patients received empiric therapy. There was no significant difference in incidence of VREB among colonized patients who did or did not receive empiric therapy (28 of 172 [16%] vs 55 of 262 [21%]; P = .22). There were 95 patients with VREB, of which the majority (83 of 95; 87%) was known to be VRE-colonized. Of the 95 VREB episodes, 29 (31%) were treated with empiric VRE therapy, whereas 66 (69%) were treated with directed therapy. No significant differences in clinical outcomes, including median duration of bacteremia (2 days vs 2 days; P = .39), recurrent VREB (3 of 29 [10%] vs 5 of 66 [8%]; P = .65), 30-day all-cause mortality (1 of 29 [3%] vs 4 of 66 [6%]; P = .62), or VRE-attributable mortality (1 of 29 [3%] vs 1 of 66 [2%]; P = .55), were observed between the empiric therapy and directed therapy groups. Kaplan-Meier curve analysis showed no significant difference in survival at 30days in allo-HSCT recipients with VREB who received empiric therapy and those who received directed therapy (97% vs 94%; P = .62). Based on our data, we recommend against empiric use of VRE-active agents for fever and neutropenia in VRE-colonized patients undergoing allo-HSCT.
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Affiliation(s)
- Mini Kamboj
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Infection Control, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Joan and Sanford Weill Cornell Medical College, New York, New York
| | - Nina Cohen
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yao-Ting Huang
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marina Kerpelev
- Information Systems, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ann Jakubowski
- Department of Medicine, Joan and Sanford Weill Cornell Medical College, New York, New York; Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kent A Sepkowitz
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Infection Control, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Joan and Sanford Weill Cornell Medical College, New York, New York
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Joan and Sanford Weill Cornell Medical College, New York, New York
| | - Susan K Seo
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Joan and Sanford Weill Cornell Medical College, New York, New York.
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6
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Dulanto Chiang A, Sinaii N, Palmore TN. Risk Factors for Viridans Group Streptococcal Bacteremia in Neutropenic and Non-neutropenic Patients: A Single Center Case-Case-Control Study. Open Forum Infect Dis 2017; 5:ofx260. [PMID: 29955617 DOI: 10.1093/ofid/ofx260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 11/27/2017] [Indexed: 11/13/2022] Open
Abstract
Background Viridans group streptococcal (VGS) bacteremia is common among neutropenic patients. Although VGS bacteremia occurs in non-neutropenic patients, risk factors are not well established. We conducted a case-case-control study to identify risk factors for VGS among neutropenic and non-neutropenic patients. Methods Patients with VGS bacteremia between January 2009 and December 2014 in our 200-bed clinical research hospital were identified using microbiology records. Neutropenic and non-neutropenic patients at the time of positive culture were matched 1:1 to controls on the basis of neutrophil count (ANC), ward, and length of stay. We extracted demographic, laboratory, medication, and other clinical data from chart reviews. Data were analyzed using McNemar's test, Wilcoxon signed-rank test, and conditional logistic regression modeling. Results Among 101 patients, 63 were neutropenic and 38 non-neutropenic at the time of VGS bacteremia. In multivariable analysis of neutropenic patients, only lower ANC predicted VGS bacteremia (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.05-0.59; P = 0.006). Recent use of vancomycin was protective (OR, 0.23; 95% CI, 0.07-0.73; P = 0.013). No clinical factors were associated with VGS in the non-neutropenic cases. Conclusions Only lower ANC nadir increased the risk for VGS bacteremia in the neutropenic group, and vancomycin was protective. Other previously described factors (chemotherapy, radiation, oral conditions) related to neutropenia were not independently associated with VGS bacteremia. No tested clinical factors predicted infection in the non-neutropenic group. Our results suggest that VGS bacteremia should be anticipated when making antimicrobial choices in profoundly neutropenic patients, and merit further exploration in non-neutropenic patients.
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Affiliation(s)
| | - Ninet Sinaii
- National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Tara N Palmore
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland.,National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, Maryland
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7
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Viridans group streptococci bloodstream infections in neutropenic adult patients with hematologic malignancy: Single center experience. Folia Microbiol (Praha) 2017; 63:141-146. [DOI: 10.1007/s12223-017-0542-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 07/30/2017] [Indexed: 01/17/2023]
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8
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Pre-engraftment bloodstream infections in acute leukemia patients undergoing unrelated cord blood transplantation following intensified myeloablative conditioning without ATG. Ann Hematol 2016; 96:115-124. [DOI: 10.1007/s00277-016-2828-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 09/19/2016] [Indexed: 12/21/2022]
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9
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Kimura M, Araoka H, Yoshida A, Yamamoto H, Abe M, Okamoto Y, Yuasa M, Kaji D, Kageyama K, Nishida A, Ishiwata K, Takagi S, Yamamoto G, Asano-Mori Y, Uchida N, Hishinuma A, Izutsu K, Wake A, Taniguchi S, Yoneyama A. Breakthrough viridans streptococcal bacteremia in allogeneic hematopoietic stem cell transplant recipients receiving levofloxacin prophylaxis in a Japanese hospital. BMC Infect Dis 2016; 16:372. [PMID: 27495798 PMCID: PMC4975918 DOI: 10.1186/s12879-016-1692-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 07/05/2016] [Indexed: 12/29/2022] Open
Abstract
Background Breakthrough viridans streptococcal bacteremia (VSB) in patients with hematological malignancy receiving levofloxacin prophylaxis is a major blood stream infection (BSI) occurring during febrile neutropenia. However, clinical data focused on VSB in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients are lacking. Methods The medical records of allo-HSCT recipients who received oral levofloxacin prophylaxis between January 2011 and August 2013 at Toranomon Hospital were reviewed to evaluate breakthrough VSB. Stored viridans streptococcal (VGS) species were identified by using sodA gene sequencing, and were assessed for drug susceptibility. Results Among the 184 allo-HSCT recipients on levofloxacin prophylaxis, 28 (15.2 %) experienced breakthrough VSB. All of the 28 recipients with VSB were treated with a cefepime-based or piperacillin/tazobactam-based regimen. The susceptibility rates of the VGS strains for levofloxacin, cefepime, piperacillin/tazobactam, meropenem, and vancomycin were 0 %, 95 %, 100 %, 100 %, and 100 %, respectively. Both the MIC50 (minimum inhibitory concentration) and the MIC90 of ceftazidim (0.5 μg/mL and 2 μg/mL, respectively) were higher than the MIC90 of all the other anti-pseudomonal beta-lactams (APBLs). Only 1 VGS strain had a penicillin MIC ≥ 2 μg/mL by the Etest (3.6 %). There were no cases with acute respiratory distress syndrome (ARDS) that was associated with VSB, although the rate of viridans group streptococcal shock syndrome was high (26 %). The crude 30-day mortality rate in the VSB group (10.7 %) did not differ significantly from that in the BSI without VSB group (9.3 %) or non-BSI group (7.0 %) (P = 0.77). Also, VSB was not a risk factor for all-cause mortality up to 60 days following allo-HSCT (P = 0.43). Conclusions APBL with increased anti-VGS activity (APBL-VA) monotherapy would typically be optimal for treating the VGS strains in this setting. Indication of adding an empiric anti-gram-positive agent to APBL-VA for treating VSB should depend on local factors, such as the susceptibility results. In addition, breakthrough VSB is probably not a major cause of death in allo-HSCT settings, where beta-lactam non-susceptible VGS and the ARDS are rare. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1692-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Muneyoshi Kimura
- Department of Infectious Diseases, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
| | - Hideki Araoka
- Department of Infectious Diseases, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Atsushi Yoshida
- Department of Infection Control and Clinical Laboratory Medicine, Dokkyo Medical University, Tochigi, Japan
| | | | - Masahiro Abe
- Department of Infectious Diseases, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Yuki Okamoto
- Department of Infection Control and Clinical Laboratory Medicine, Dokkyo Medical University, Tochigi, Japan
| | | | - Daisuke Kaji
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Kosei Kageyama
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Aya Nishida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | | | | | - Go Yamamoto
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | | | - Naoyuki Uchida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Akira Hishinuma
- Department of Infection Control and Clinical Laboratory Medicine, Dokkyo Medical University, Tochigi, Japan
| | - Koji Izutsu
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Atsushi Wake
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Shuichi Taniguchi
- Department of Hematology, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Akiko Yoneyama
- Department of Infectious Diseases, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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10
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Mayer S, Pastores SM, Riedel E, Maloy M, Jakubowski AA. Short- and long-term outcomes of adult allogeneic hematopoietic stem cell transplant patients admitted to the intensive care unit in the peritransplant period. Leuk Lymphoma 2016; 58:382-390. [PMID: 27347608 DOI: 10.1080/10428194.2016.1195499] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Survival of allogeneic hematopoietic stem cell transplant (aHSCT) recipients in the intensive care unit (ICU) has been poor. We retrospectively analyzed the short- and long-term outcomes of aHSCT patients admitted to the ICU over a 12-year period. Of 1235 adult patients who had aHSCT between 2002 and 2013, 161 (13%) were admitted to the ICU. The impact of clinical parameters was assessed and outcomes were compared for the periods 2002-2007 and 2008-2013. The ICU, in-hospital, 1- and 5-year survival rates were 64.6%, 46%, 33% and 20%, respectively. Mechanical ventilation and vasopressor use predicted for worse hospital- and overall survival (OS). After 2008, the requirement for mechanical ventilation and vasopressors, and the diagnosis of sepsis were reduced. While hospital mortality decreased from 69% to 44%, long-term survival (LTS) remained unchanged. Late deaths, due to causes not associated with the ICU such as relapse and graft-versus-host disease, increased. As thresholds for transplant are lowered, improvements in ICU outcomes for aHSCT recipients may be limited.
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Affiliation(s)
- Sebastian Mayer
- a Department of Medicine , New York Presbyterian Hospital, Joan and Sanford I Weill Medical College, Cornell University , New York , USA
| | - Stephen M Pastores
- a Department of Medicine , New York Presbyterian Hospital, Joan and Sanford I Weill Medical College, Cornell University , New York , USA.,b Departments of Anesthesiology and Critical Care Medicine , Memorial Sloan-Kettering Cancer Center , New York , USA
| | - Elyn Riedel
- c Epidemiology and Biostatistics , Memorial Sloan-Kettering Cancer Center , New York , USA
| | - Molly Maloy
- d Memorial Sloan Kettering Cancer Center , New York , USA
| | - Ann A Jakubowski
- e Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , USA.,f Joan and Sanford I Weill Cornell Medical College, Cornell University , New York , New York , USA
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11
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Shono Y, Docampo MD, Peled JU, Perobelli SM, Velardi E, Tsai JJ, Slingerland AE, Smith OM, Young LF, Gupta J, Lieberman SR, Jay HV, Ahr KF, Rodriguez KAP, Xu K, Calarfiore M, Poeck H, Caballero S, Devlin SM, Rapaport F, Dudakov JA, Hanash AM, Gyurkocza B, Murphy GF, Gomes C, Liu C, Moss EL, Falconer SB, Bhatt AS, Taur Y, Pamer EG, van den Brink MR, Jenq RR. Increased GVHD-related mortality with broad-spectrum antibiotic use after allogeneic hematopoietic stem cell transplantation in human patients and mice. Sci Transl Med 2016; 8:339ra71. [PMID: 27194729 PMCID: PMC4991773 DOI: 10.1126/scitranslmed.aaf2311] [Citation(s) in RCA: 361] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/04/2016] [Indexed: 12/13/2022]
Abstract
Intestinal bacteria may modulate the risk of infection and graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Allo-HSCT recipients often develop neutropenic fever, which is treated with antibiotics that may target anaerobic bacteria in the gut. We retrospectively examined 857 allo-HSCT recipients and found that treatment of neutropenic fever with imipenem-cilastatin and piperacillin-tazobactam antibiotics was associated with increased GVHD-related mortality at 5 years (21.5% for imipenem-cilastatin-treated patients versus 13.1% for untreated patients, P = 0.025; 19.8% for piperacillin-tazobactam-treated patients versus 11.9% for untreated patients, P = 0.007). However, two other antibiotics also used to treat neutropenic fever, aztreonam and cefepime, were not associated with GVHD-related mortality (P = 0.78 and P = 0.98, respectively). Analysis of stool specimens from allo-HSCT recipients showed that piperacillin-tazobactam administration was associated with perturbation of gut microbial composition. Studies in mice demonstrated aggravated GVHD mortality with imipenem-cilastatin or piperacillin-tazobactam compared to aztreonam (P < 0.01 and P < 0.05, respectively). We found pathological evidence for increased GVHD in the colon of imipenem-cilastatin-treated mice (P < 0.05), but no difference in the concentration of short-chain fatty acids or numbers of regulatory T cells. Notably, imipenem-cilastatin treatment of mice with GVHD led to loss of the protective mucus lining of the colon (P < 0.01) and the compromising of intestinal barrier function (P < 0.05). Sequencing of mouse stool specimens showed an increase in Akkermansia muciniphila (P < 0.001), a commensal bacterium with mucus-degrading capabilities, raising the possibility that mucus degradation may contribute to murine GVHD. We demonstrate an underappreciated risk for the treatment of allo-HSCT recipients with antibiotics that may exacerbate GVHD in the colon.
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Affiliation(s)
- Yusuke Shono
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa D. Docampo
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan U. Peled
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Medical College of Cornell University, New York, New York
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Suelen M. Perobelli
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Enrico Velardi
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy
| | - Jennifer J. Tsai
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ann E. Slingerland
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Odette M. Smith
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lauren F. Young
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jyotsna Gupta
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sophia R. Lieberman
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hillary V. Jay
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katya F. Ahr
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kori A. Porosnicu Rodriguez
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ke Xu
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marco Calarfiore
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hendrik Poeck
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Silvia Caballero
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M. Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Franck Rapaport
- Human Oncology & Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jarrod A. Dudakov
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
- Program in Immunology, Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Alan M. Hanash
- Weill Medical College of Cornell University, New York, New York
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Boglarka Gyurkocza
- Weill Medical College of Cornell University, New York, New York
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - George F. Murphy
- Program in Dermatopathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Camilla Gomes
- Program in Dermatopathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chen Liu
- Departments of Pathology and Laboratory Medicine, New Jersey Medical School and Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Eli L. Moss
- Department of Medicine and Genetics, Stanford University, Stanford, California
| | - Shannon B. Falconer
- Department of Medicine and Genetics, Stanford University, Stanford, California
| | - Ami S. Bhatt
- Department of Medicine and Genetics, Stanford University, Stanford, California
| | - Ying Taur
- Weill Medical College of Cornell University, New York, New York
- Infectious Diseases Service, Lucille Castori Center for Microbes, Inflammation & Cancer, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric G. Pamer
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Medical College of Cornell University, New York, New York
- Infectious Diseases Service, Lucille Castori Center for Microbes, Inflammation & Cancer, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marcel R.M. van den Brink
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Medical College of Cornell University, New York, New York
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert R. Jenq
- Weill Medical College of Cornell University, New York, New York
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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12
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Jenq RR, Taur Y, Devlin SM, Ponce DM, Goldberg JD, Ahr KF, Littmann ER, Ling L, Gobourne AC, Miller LC, Docampo MD, Peled JU, Arpaia N, Cross JR, Peets TK, Lumish MA, Shono Y, Dudakov JA, Poeck H, Hanash AM, Barker JN, Perales MA, Giralt SA, Pamer EG, van den Brink MRM. Intestinal Blautia Is Associated with Reduced Death from Graft-versus-Host Disease. Biol Blood Marrow Transplant 2015; 21:1373-83. [PMID: 25977230 DOI: 10.1016/j.bbmt.2015.04.016] [Citation(s) in RCA: 516] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 04/13/2015] [Indexed: 02/07/2023]
Abstract
The relationship between intestinal microbiota composition and acute graft-versus-host disease (GVHD) after allogeneic blood/marrow transplantation (allo-BMT) is not well understood. Intestinal bacteria have long been thought to contribute to GVHD pathophysiology, but recent animal studies in nontransplant settings have found that anti-inflammatory effects are mediated by certain subpopulations of intestinal commensals. Hypothesizing that a more nuanced relationship may exist between the intestinal bacteria and GVHD, we evaluated the fecal bacterial composition of 64 patients 12 days after BMT. We found that increased bacterial diversity was associated with reduced GVHD-related mortality. Furthermore, harboring increased amounts of bacteria belonging to the genus Blautia was associated with reduced GVHD lethality in this cohort and was confirmed in another independent cohort of 51 patients from the same institution. Blautia abundance was also associated with improved overall survival. We evaluated the abundance of Blautia with respect to clinical factors and found that loss of Blautia was associated with treatment with antibiotics that inhibit anaerobic bacteria and receiving total parenteral nutrition for longer durations. We conclude that increased abundance of commensal bacteria belonging to the Blautia genus is associated with reduced lethal GVHD and improved overall survival.
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Affiliation(s)
- Robert R Jenq
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York.
| | - Ying Taur
- Weill Cornell Medical College, New York, New York; Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M Devlin
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Doris M Ponce
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Jenna D Goldberg
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Katya F Ahr
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric R Littmann
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lilan Ling
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Asia C Gobourne
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Liza C Miller
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa D Docampo
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan U Peled
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Nicholas Arpaia
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Justin R Cross
- Cell Metabolism Core, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tatanisha K Peets
- Department of Nutrition, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa A Lumish
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yusuke Shono
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jarrod A Dudakov
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hendrik Poeck
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alan M Hanash
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Juliet N Barker
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Sergio A Giralt
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Eric G Pamer
- Weill Cornell Medical College, New York, New York; Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marcel R M van den Brink
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
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13
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Impact of peri-transplant vancomycin and fluoroquinolone administration on rates of bacteremia in allogeneic hematopoietic stem cell transplant (HSCT) recipients: a 12-year single institution study. J Infect 2014; 69:341-351. [PMID: 24931578 DOI: 10.1016/j.jinf.2014.06.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 05/29/2014] [Accepted: 06/04/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND We analyzed the effect of peri-transplant prophylaxis on the epidemiology of bacteremia in a 12-year contemporary cohort of allogeneic HSCT recipients at our center. METHODS This was an observational study of 1052 consecutive adult HSCT from 2000 to 2011. Formal prophylaxis with vancomycin only, fluoroquinolone (FQ) only, or vancomycin + FQ was implemented in 2006. The cumulative incidence of day 100 bacteremia was compared between the Early Period (2000-2005) and the Recent Period (2006-2011). Predictors for pre-engraftment bacteremia were analyzed with Cox-proportional hazard models in a subcohort of 821 HSCT who received myeloablative or reduced intensity conditioning (MA/RIC). RESULTS The incidence of bacteremia decreased in the Recent Period (32% vs 27%; P = 0.002), whereas the rates of resistance in gram-negative rods (GNR) and vancomycin-resistant enterococci (VRE) were similar between the two Periods (P values are not statistically significant.) In multivariate analyses, prophylaxis with vancomycin only or vancomycin + FQ was protective (HR = 0.5; CI = 0.30-0.72) and (HR = 0.3; CI = 0.12-0.52, P < 0.01). Vancomycin or vancomycin + FQ eliminated viridans streptococcal bacteremia (VSB); vancomycin + FQ decreased GNR bacteremia (HR = 0.35; CI = 0.15-0.85). CONCLUSIONS Vancomycin-based prophylaxis peri-transplant in MA/RIC HSCT was associated with elimination of VSB and may be considered at centers with high incidence of this infection.
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Fuji S, Kapp M, Einsele H. Possible implication of bacterial infection in acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Front Oncol 2014; 4:89. [PMID: 24795865 PMCID: PMC4006055 DOI: 10.3389/fonc.2014.00089] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 04/10/2014] [Indexed: 12/24/2022] Open
Abstract
Graft-versus-host disease (GVHD) is still one of the major causes of morbidity and mortality in allogeneic hematopoietic stem cell transplantation (HSCT). In the pathogenesis of acute GVHD, it has been established that donor-derived T-cells activated in the recipient play a major role in GVHD in initiation and maintenance within an inflammatory cascade. To reduce the risk of GVHD, intensification of GVHD prophylaxis like T-cell depletion is effective, but it inevitably increases the risk of infectious diseases and abrogates beneficial graft-versus-leukemia effects. Although various cytokines are considered to play an important role in the pathogenesis of GVHD, GVHD initiation is such a complex process that cannot be prevented by means of single inflammatory cytokine inhibition. Thus, efficient methods to control the whole inflammatory milieu both on cellular and humoral view are needed. In this context, infectious diseases can theoretically contribute to an elevation of inflammatory cytokines after allogeneic HSCT and activation of various subtypes of immune effector cells, which might in summary lead to an aggravation of acute GVHD. The appropriate treatments or prophylaxis of bacterial infection during the early phase after allogeneic HSCT might be beneficial to reduce not only infectious-related but also GVHD-related mortality. Here, we aim to review the literature addressing the interactions of bacterial infections and GVHD after allogeneic HSCT.
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Affiliation(s)
- Shigeo Fuji
- Division of Hematology, Department of Internal Medicine II, University Hospital of Würzburg , Würzburg , Germany ; Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital , Tokyo , Japan
| | - Markus Kapp
- Division of Hematology, Department of Internal Medicine II, University Hospital of Würzburg , Würzburg , Germany
| | - Hermann Einsele
- Division of Hematology, Department of Internal Medicine II, University Hospital of Würzburg , Würzburg , Germany
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15
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Shelburne SA, Lasky RE, Sahasrabhojane P, Tarrand JT, Rolston KVI. Development and validation of a clinical model to predict the presence of β-lactam resistance in viridans group streptococci causing bacteremia in neutropenic cancer patients. Clin Infect Dis 2014; 59:223-30. [PMID: 24755857 DOI: 10.1093/cid/ciu260] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Concern for serious infection due to β-lactam-resistant viridans group streptococci (VGS) is a major factor driving empiric use of an anti-gram-positive antimicrobial in patients with febrile neutropenia. We sought to develop and validate a prediction model for the presence of β-lactam resistance in VGS causing bloodstream infection (BSI) in neutropenic patients. METHODS Data from 569 unique cases of VGS BSI in neutropenic patients from 2000 to 2010 at the MD Anderson Cancer Center were used to develop the clinical prediction model. Validation was done using 163 cases from 2011 to 2013. In vitro activity of β-lactam agents was determined for 2011-2013 VGS bloodstream isolates. RESULTS In vitro resistance to β-lactam agents commonly used in the empiric treatment of febrile neutropenia was observed only for VGS isolates with a penicillin minimum inhibitory concentration (MIC) of ≥ 2 µg/mL. One hundred twenty-nine of 732 patients (17%) were infected with VGS strains with a penicillin MIC ≥ 2 µg/mL. For the derivation and validation cohorts, 98% of patients infected by VGS with a penicillin MIC of ≥ 2 µg/mL had at least 1 of the following risk factors: current use of a β-lactam as antimicrobial prophylaxis, receipt of a β-lactam antimicrobial in the previous 30 days, or nosocomial VGS BSI onset. Limiting empiric anti-gram-positive therapy to neutropenic patients having at least 1 of these 3 risk factors would have reduced such use by 42%. CONCLUSIONS Simple clinical criteria can assist with targeting of anti-gram-positive therapy to febrile neutropenic patients at risk of serious β-lactam-resistant VGS infection.
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Affiliation(s)
| | - Robert E Lasky
- Department of Center for Clinical Research and Evidence-Based Medicine, University of Texas Health Science Center at Houston
| | | | - Jeffrey T Tarrand
- Department of Laboratory Medicine, MD Anderson Cancer Center, Houston, Texas
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16
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Freifeld AG, Razonable RR. Viridans group streptococci in febrile neutropenic cancer patients: what should we fear? Clin Infect Dis 2014; 59:231-3. [PMID: 24755859 DOI: 10.1093/cid/ciu264] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Alison G Freifeld
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha
| | - Raymund R Razonable
- Division of Infectious Diseases, and the William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
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17
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Cost analysis of dental services needed before hematopoietic cell transplantation. Oral Surg Oral Med Oral Pathol Oral Radiol 2014; 117:59-66. [DOI: 10.1016/j.oooo.2013.08.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/15/2013] [Accepted: 08/21/2013] [Indexed: 11/22/2022]
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Taur Y, Pamer EG. The intestinal microbiota and susceptibility to infection in immunocompromised patients. Curr Opin Infect Dis 2013; 26:332-7. [PMID: 23806896 PMCID: PMC4485384 DOI: 10.1097/qco.0b013e3283630dd3] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW Many infections of immunocompromised patients originate from the gastrointestinal tract. The pathogenesis of these infections often begins with alteration of the intestinal microbiota. Understanding the microbiota and how it can either cause or prevent infection is vital for the development of more effective prevention and treatment of these infections. This article reviews and discusses recent work providing insight into the intestinal microbiota of these at-risk immunocompromised patients. RECENT FINDINGS Studies continue to support the premise that commensal bacteria, largely anaerobic, serve to maintain microbial stability and colonization resistance by preventing overgrowth or domination with more pathogenic bacteria, through interactions within the microbial community and with the host. In patients with immune suppression due to high-dose chemotherapy or hematopoietic stem cell transplantation, disruption of the microbiota through antibiotics as well as impairment of host immunity gives rise to perturbations favoring intestinal domination by pathogenic species, leading to increased bacterial translocation and susceptibility to systemic infection. SUMMARY An understanding of the intestinal microbiota and the impact of antibiotics will help to guide our treatment of these gut-originating infections.
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Affiliation(s)
- Ying Taur
- Infectious Diseases, Memorial Sloan Kettering Cancer Center, Sloan Kettering Institute, New York, New York 10065, USA.
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19
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Risk factor analysis of bloodstream infection in pediatric patients after hematopoietic stem cell transplantation. J Pediatr Hematol Oncol 2013; 35:76-80. [PMID: 22995926 DOI: 10.1097/mph.0b013e3182677f35] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Bloodstream infection (BSI) is a recognized cause of morbidity and mortality in children after hematopoietic stem cell transplantation (HSCT). However, there are limited reports on BSI after HSCT in pediatric patients in multiple centers. This study was a retrospective cohort analysis of consecutive patients who underwent allogeneic and autologous HSCT at the Department of Paediatrics, Hokkaido University Hospital, between 1988 and 2009; the Department of Paediatrics, Sapporo Hokuyu Hospital, between 2007 and 2009; and the Department of Paediatrics, Asahikawa Medical University, between 1989 and 2009. A total of 277 patients underwent HSCT during the study period. In this multicenter analysis, cases of BSI after HSCT were recorded in the early posttransplant period (within the first 100 d), and BSI was observed in 24 of 277 HSCT patients. Multivariate analysis showed that nonmalignant disease was an independent factor associated with BSI after HSCT (hazard ratio 6.3 for aplastic anemia or Wiskott-Aldrich syndrome patients; confidence interval, 1.4-12.8; P = 0.012). We conclude that aplastic anemia and Wiskott-Aldrich syndrome were the novel risk factors for BSI in pediatric patients after HSCT.
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20
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Taur Y, Xavier JB, Lipuma L, Ubeda C, Goldberg J, Gobourne A, Lee YJ, Dubin KA, Socci ND, Viale A, Perales MA, Jenq RR, van den Brink MRM, Pamer EG. Intestinal domination and the risk of bacteremia in patients undergoing allogeneic hematopoietic stem cell transplantation. Clin Infect Dis 2012; 55:905-14. [PMID: 22718773 DOI: 10.1093/cid/cis580] [Citation(s) in RCA: 677] [Impact Index Per Article: 56.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Bacteremia is a frequent complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). It is unclear whether changes in the intestinal microbiota during allo-HSCT contribute to the development of bacteremia. We examined the microbiota of patients undergoing allo-HSCT, and correlated microbial shifts with the risk of bacteremia. METHODS Fecal specimens were collected longitudinally from 94 patients undergoing allo-HSCT, from before transplant until 35 days after transplant. The intestinal microbiota was characterized by 454 pyrosequencing of the V1-V3 region of bacterial 16S ribosomal RNA genes. Microbial diversity was estimated by grouping sequences into operational taxonomic units and calculating the Shannon diversity index. Phylogenetic classification was obtained using the Ribosomal Database Project classifier. Associations of the microbiota with clinical predictors and outcomes were evaluated. RESULTS During allo-HSCT, patients developed reduced diversity, with marked shifts in bacterial populations inhabiting the gut. Intestinal domination, defined as occupation of at least 30% of the microbiota by a single predominating bacterial taxon, occurred frequently. Commonly encountered dominating organisms included Enterococcus, Streptococcus, and various Proteobacteria. Enterococcal domination was increased 3-fold by metronidazole administration, whereas domination by Proteobacteria was reduced 10-fold by fluoroquinolone administration. As a predictor of outcomes, enterococcal domination increased the risk of Vancomycin-resistant Enterococcus bacteremia 9-fold, and proteobacterial domination increased the risk of gram-negative rod bacteremia 5-fold. CONCLUSIONS During allo-HSCT, the diversity and stability of the intestinal flora are disrupted, resulting in domination by bacteria associated with subsequent bacteremia. Assessment of fecal microbiota identifies patients at highest risk for bloodstream infection during allo-HCST.
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Affiliation(s)
- Ying Taur
- Infectious Disease Service, Department of Medicine, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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21
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Infections in Leukemia and Hematopoietic Stem Cell Transplantation. LEUKEMIA AND RELATED DISORDERS 2012. [PMCID: PMC7178857 DOI: 10.1007/978-1-60761-565-1_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Infections are one of the most common complications in patients diagnosed with leukemia and serve as a major obstacle to treatment. Through the early 1970s, infections were the most common cause of death in patients diagnosed with acute leukemia, but improvement in treatment and supportive care over the past few decades, coupled with expanded prophylaxis and prevention regimens, have led to reduction in both the frequency and severity of infections. Regardless, due in part to an aging cancer population and the diversity of cancer treatments and procedures, infectious diseases remain a major cause of morbidity and mortality in patients with leukemia.
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Sauter C, Abboud M, Jia X, Heller G, Gonzales AM, Lubin M, Hawke R, Perales MA, van den Brink MR, Giralt S, Papanicolaou G, Scaradavou A, Small TN, Barker JN. Serious infection risk and immune recovery after double-unit cord blood transplantation without antithymocyte globulin. Biol Blood Marrow Transplant 2011; 17:1460-71. [PMID: 21310254 DOI: 10.1016/j.bbmt.2011.02.001] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Accepted: 02/02/2011] [Indexed: 10/18/2022]
Abstract
Factors contributing to infection risk after cord blood transplantation (CBT) include the use of anti-thymocyte globulin (ATG), prolonged neutropenia, and failure to transfer immunity. In the present study, we investigated the potential of double-unit CBT without ATG to reduce the risk of infection and evaluated the nature of serious infections in the first year after CBT using this approach. Seventy-two predominantly adult patients underwent CBT for hematologic malignancies; of these, 52 patients received myeloablative conditioning, and 20 received nonmyeloablative conditioning. The peak incidences of bacterial infections (32%), fungal infections (14%), and bacterial/fungal pneumonias (10%) occurred in the first 30 days posttransplantation. Three such infections contributed to early mortality. The peak incidence of viral infections was 31-60 days posttransplantation, affecting 30% of patients. Cytomegalovirus (CMV) was the most common viral infection. CMV infections occurring before day 120 (n = 23) had no relationship with graft-versus-host disease (GVHD), whereas CMV infections occurring after day 120 (n = 5), along with all cases of Epstein-Barr virus viremia (n = 5) and adenoviral enteritis (n = 2), occurred exclusively in the context of GVHD therapy or corticosteroid use for another indication. Viral infections had the highest lethality: 2 were a direct cause of death, and 3 contributed to death. Patients exhibited steady immune recovery, achieving a median CD3(+)4(+) T cell count >200 cells/μL by day 120 post-CBT, and no infection-related deaths occurred after day 120. Our results suggest that double-unit CBT without ATG is associated with prompt T cell recovery, and, unlike in CBT incorporating ATG, infection is rarely a primary cause of death. However, CBT without ATG is associated with a significant risk of GVHD, and serious infections remain a challenge, especially in the setting of GVHD. New strategies are needed to further reduce infectious complications after CBT; these will require earlier neutrophil recovery and more effective prevention of GVHD, ideally without the profound T cell depletion associated with ATG therapy.
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Affiliation(s)
- Craig Sauter
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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23
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Lingaratnam S, Slavin MA, Mileshkin L, Solomon B, Burbury K, Seymour JF, Sharma R, Koczwara B, Kirsa SW, Davis ID, Prince M, Szer J, Underhill C, Morrissey O, Thursky KA. An Australian survey of clinical practices in management of neutropenic fever in adult cancer patients 2009. Intern Med J 2011; 41:110-20. [DOI: 10.1111/j.1445-5994.2010.02342.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Kamboj M, Chung D, Seo SK, Pamer EG, Sepkowitz KA, Jakubowski AA, Papanicolaou G. The changing epidemiology of vancomycin-resistant Enterococcus (VRE) bacteremia in allogeneic hematopoietic stem cell transplant (HSCT) recipients. Biol Blood Marrow Transplant 2010; 16:1576-81. [PMID: 20685257 DOI: 10.1016/j.bbmt.2010.05.008] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Accepted: 05/14/2010] [Indexed: 01/29/2023]
Abstract
The impact of the rising prevalence of vancomycin-resistant Enterococcus (VRE) prior to hematopoietic stem cell transplantation (HSCT) and changes in transplant techniques on risk of VREB (VRE bacteremia) early after HSCT is not known. This is a retrospective study of 247 adult patients who underwent allogeneic HSCT in the years 2008 and 2009 at the Memorial Sloan-Kettering Cancer Center. Sixty-eight of 247 (27.5%) patients were VRE colonized on pretransplant screening. VRE was the leading cause of bacteremia in the first 30 days after HSCT; 23 of 43 (53.5%) patients with positive blood cultures had VRE. Only 13 (57%) of the 23 patients with early VREB were colonized with VRE on pre-HSCT screening cultures. Mortality was directly attributable to VRE infection in 9% of patients with early VREB. VRE is emerging as the most common cause of preengraftment bacteremia in patients undergoing allogeneic HSCT, and is associated with substantial mortality. Pre-HSCT screening for VRE with stool cultures will not identify all patients who are at risk for VREB. The use of alternate agents with activity against Gram-positive bacteria for fever and neutropenia early after HSCT should be evaluated further in prospective studies.
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Affiliation(s)
- Mini Kamboj
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
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25
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Jakubowski AA, Small TN, Young JW, Kernan NA, Castro-Malaspina H, Hsu KC, Perales MA, Collins N, Cisek C, Chiu M, van den Brink MRM, O'Reilly RJ, Papadopoulos EB. T cell depleted stem-cell transplantation for adults with hematologic malignancies: sustained engraftment of HLA-matched related donor grafts without the use of antithymocyte globulin. Blood 2007; 110:4552-9. [PMID: 17717135 PMCID: PMC2234775 DOI: 10.1182/blood-2007-06-093880] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Antithymocyte globulin (ATG) has been used in allogeneic stem-cell transplantation to prevent graft rejection and graft-versus-host disease (GvHD). Its use, however, has been associated with delayed T-cell reconstitution and prolonged susceptibility to opportunistic infections (OIs) especially in patients undergoing T cell-depleted (TCD) transplantation. Recently, a prospective trial was conducted in 52 adult patients (median age, 47 years) with various hematologic malignancies undergoing TCD transplantation from HLA-matched related donors without the use of ATG. The cytoreductive regimen consisted of hyperfractionated total body irradiation (HFTBI), thiotepa, and fludarabine. The preferred source of the graft was peripheral blood stem cells (PBSCs). No additional graft rejection or GvHD prophylaxis was given. All evaluable patients engrafted without any immune-mediated graft rejections. Disease-free survival (DFS) at 3 years was 61% in all patients, and 70% in patients with standard-risk disease. Acute GvHD was limited to grade 2 in 8% and chronic GvHD in 9% of patients. Life-threatening OIs occurred in 3 of 52 patients and was fatal in 1. This study demonstrates durable engraftment with a low incidence of GvHD despite the lack of ATG, as well as the curative potential of this regimen.
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Affiliation(s)
- Ann A Jakubowski
- Adult Allogeneic Bone Marrow Transplant Service, Division of Hematologic-Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, Weill Medical College of Cornell University, New York, NY 10065, USA.
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26
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Weinstock DM, Conlon M, Iovino C, Aubrey T, Gudiol C, Riedel E, Young JW, Kiehn TE, Zuccotti G. Colonization, bloodstream infection, and mortality caused by vancomycin-resistant enterococcus early after allogeneic hematopoietic stem cell transplant. Biol Blood Marrow Transplant 2007; 13:615-21. [PMID: 17448922 DOI: 10.1016/j.bbmt.2007.01.078] [Citation(s) in RCA: 167] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2006] [Accepted: 01/21/2007] [Indexed: 11/25/2022]
Abstract
Bloodstream infection caused by vancomycin-resistant enterococcus (VRE) is associated with very high mortality among allogeneic hematopoietic stem cell transplant (alloHSCT) recipients. However, it remains unclear whether VRE bloodstream infection directly causes mortality in the early posttransplant period or is simply a marker of poor outcome. To determine the risk factors for VRE bloodstream infection and its effect on outcome, we followed 92 patients screened for stool colonization by VRE upon admission for alloHSCT. Patient records were reviewed to determine outcomes, including mortality and microbiologic failure. Colonization by VRE was extremely common, occurring in 40.2% of patients. VRE bloodstream infection developed in 34.2% of colonized patients by day +35, compared to 1.8% without VRE colonization (P < .01). VRE bloodstream infection was associated with a significant decrement in survival and frequent microbiologic failure, despite treatment with linezolid and/or daptomycin. Five (35.7%) of 14 patients with VRE bloodstream infection had attributable mortality or contributing mortality from the infection. Strain typing by pulsed-field gel electrophoresis identified 9 different VRE strains among the 37 colonized patients and 5 patients with different strains recovered from the stool and the blood. In conclusion, stool screening effectively identified patients at extremely high risk for VRE bloodstream infection. The high mortality of VRE in the early posttransplant period supports the use of empiric antibiotics with activity against VRE during periods of fever and neutropenia in colonized patients.
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Affiliation(s)
- David M Weinstock
- Adult Allogeneic Bone Marrow Transplant Service, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
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Bruckner L, Gigliotti F. Viridans Group Streptococcal Infections Among Children With Cancer and the Importance of Emerging Antibiotic Resistance. ACTA ACUST UNITED AC 2006; 17:153-60. [PMID: 16934710 DOI: 10.1053/j.spid.2006.06.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Viridans group streptococci (VGS) are major pathogens among children with cancer or receiving hematopoietic stem cell transplantation and are associated with considerable morbidity and mortality rates. The incidence and severity of VGS infections have increased during the past 15 years and account for as many as one third of all bacteremic episodes. Risk factors include severe neutropenia, mucositis, gastrointestinal toxicity, pneumonia, younger age, and high-intensity chemotherapy (especially cytosine arabinoside). VGS no longer can be assumed to be susceptible to penicillin because as many as 37 percent of VGS isolates harbor high levels of resistance (minimum inhibitory concentration >4 microg/mL). Furthermore, resistance to multiple classes of antibiotics, including beta-lactams and fluoroquinolones, has now been documented and is increasing in prevalence. In this article, we present a brief overview of VGS, describe the clinical spectrum of VGS-related diseases in children with cancer, and review the recent data regarding the incidence, clinical significance, and management of emerging antibiotic resistance among VGS.
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Affiliation(s)
- Lauren Bruckner
- Department of Pediatrics, Division of Hematology/Oncology/HSCT, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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Park SH, Choi SM, Lee DG, Choi JH, Yoo JH, Lee JW, Min WS, Shin WS, Kim CC. Current trends of infectious complications following hematopoietic stem cell transplantation in a single center. J Korean Med Sci 2006; 21:199-207. [PMID: 16614501 PMCID: PMC2733991 DOI: 10.3346/jkms.2006.21.2.199] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study was to analyze the infectious complications after hematopoietic stem cell transplantation (HSCT) according to the recent changes of HSCT. Medical records of 379 adult patients who underwent HSCT consecutively at Catholic HSCT Center from January 2001 to December 2002 were reviewed retrospectively. Allogeneic HSCT accounted for 75.7% (287/379) and autologous HSCT for 24.3% (92/379). During pre-engraftment period, bacterial infection was predominant, and E. coli was still the most common organism. After engraftment, viral infection was predominant. The incidence of invasive fungal infection showed bimodal distribution with peak correlated with neutropenia and graft-versus-host disease (GVHD). The overall mortality and infection-related mortality rates according to 3 periods were as follows; during pre-engraftment, 3.16% (12/379) and 1.8% (7/379); during midrecovery period, 7.9% (29/367) and 4.1% (15/367); during late-recovery period, 26.9% (91/338), and 15.9% (54/338). Risk factors for infection-related mortality were as follows; during pre-engraftment period, fungal infection and septic shock; during the mid-recovery period, hemorrhagic cystitis and delayed engraftment; during the late-recovery period, fungal infection, chronic GVHD, and relapse. In conclusion, infection was still one of the main complications after HSCT and highly contributes to mortality. The early diagnosis and the effective vaccination strategy are needed for control of infections.
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Affiliation(s)
- Sun Hee Park
- Department of Internal Medicine, The Catholic Hematopoietic Stem Cell Transplantation Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Su-Mi Choi
- Department of Internal Medicine, The Catholic Hematopoietic Stem Cell Transplantation Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Dong-Gun Lee
- Department of Internal Medicine, The Catholic Hematopoietic Stem Cell Transplantation Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jung-Hyun Choi
- Department of Internal Medicine, The Catholic Hematopoietic Stem Cell Transplantation Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jin-Hong Yoo
- Department of Internal Medicine, The Catholic Hematopoietic Stem Cell Transplantation Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jong-Wook Lee
- Department of Internal Medicine, The Catholic Hematopoietic Stem Cell Transplantation Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Woo-Sung Min
- Department of Internal Medicine, The Catholic Hematopoietic Stem Cell Transplantation Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Wan-Shik Shin
- Department of Internal Medicine, The Catholic Hematopoietic Stem Cell Transplantation Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Chun-Choo Kim
- Department of Internal Medicine, The Catholic Hematopoietic Stem Cell Transplantation Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
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Almyroudis NG, Fuller A, Jakubowski A, Sepkowitz K, Jaffe D, Small TN, Kiehn TE, Pamer E, Papanicolaou GA. Pre- and post-engraftment bloodstream infection rates and associated mortality in allogeneic hematopoietic stem cell transplant recipients. Transpl Infect Dis 2005; 7:11-7. [PMID: 15984943 DOI: 10.1111/j.1399-3062.2005.00088.x] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We report on bloodstream infection (BSI) rates, risk factors, and outcome in a cohort of 298 adult and pediatric hematopoietic stem cell transplantation (HSCT) recipients at Memorial Sloan-Kettering Hospital from September 1999 through June 2003. Methods. Prospective surveillance study. BSI rates are reported per 10,000 HSCT days. Date of engraftment is defined as the first of at least 3 consecutive dates of absolute neutrophil count >500/mm(3) after stem cell infusion. BSI severity grades: severe (intravenous antibiotics), life threatening (sepsis), or fatal (caused or contributed to death). Results. The incidence of pre- and post-engraftment BSI was 22% and 19.5%, respectively. Pre-engraftment highest rates were observed for viridans streptococci (58), Enterobacteriaceae (39), and Enterococcus faecium (34). Post-engraftment rates ranged from 0.2 to 2.9 without any predominant pathogen. In multivariate analyses, pre-engraftment BSI was associated with diagnosis of chronic myelogenous leukemia, age >18 years and peripheral blood stem cell graft; post-engraftment BSI was associated with acute graft-versus-host disease, neutropenia, and liver or kidney dysfunction. Attributable mortality was 12.5% and 1.7% for pre- and post-engraftment BSI, respectively. BSI fatality rates were 24% for viridans streptococci, 8% for E. faecium, 11% for Staphylococcus aureus, and 67% for Candida. Conclusions. Pre-engraftment BSI, especially by viridans streptococci and E. faecium, was associated with substantial attributable mortality. Post-engraftment BSI was a marker of post-transplant complications and rarely the primary cause of death.
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Affiliation(s)
- N G Almyroudis
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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