A Japanese single-hospital observational trial with a retrospective case-control analysis of varicella zoster virus reactivation after autologous peripheral blood stem cell transplantation

Incidence and risk factors of opportunistic infections after autologous stem cell transplantation: a nationwide, population-based cohort study in Korea

Several guidelines classify autologous stem cell transplantation (ASCT) as a low to intermediate risk group for infection. In a nationwide population-based study, using the Korean Health Insurance Review and Assessment Service database, patients with lymphoma and multiple myeloma (MM) who underwent ASCT from 2002 to 2016 were retrospectively analyzed. Cumulative incidence rates (CIRs) and risk factors of opportunistic infections were investigated. CIRs of fungal, Varicella zoster virus (VZV), cytomegalovirus (CMV), and Pneumocystis jirovecii infections in lymphoma were 7.9%, 16.0%, 7.4%, and 5.1%, respectively, and CIRs in MM were 6.3%, 19.1%, 4.2%, and 5.6%, respectively. Fungal infection was significantly higher in patients with previous infection (Hazard ratio (HR) 2.003, p = 0.005) in lymphoma. Incidence of CMV infection was significantly higher in patients with prior CMV infection: HR 4.920, p < 0.001 (lymphoma); HR 3.022, p = 0.030 (MM). VZV infection was significantly lower in patients receiving prophylaxis: HR 0.082, p < 0.001 (lymphoma); HR 0.096, p < 0.001 (MM). For P. jirovecii infection, busulfex and melphalan conditioning (HR 1.875, p = 0.032) and previous P. jirovecii infection (HR 4.810, p < 0.001) had a higher incidence in MM. Patients who underwent ASCT should receive VZV prophylaxis and prophylaxis for fungal and P. jirovecii may be considered in patients with previous same infection.

Herpes Zoster prophylaxis with low-dose acyclovir in patients with malignant lymphoma and multiple myeloma treated with autologous stem cell transplantation (ASCT)

BACKGROUND

Herpes zoster (HZ) is a frequent complication after autologous stem cell transplantation (ASCT). The option of zoster prophylaxis with an antiviral drug is described in the literature, but there is no consensus on the drug and the dosage.

PATIENTS AND METHODS

We analyzed the records of 310 patients treated with ASCT who were controlled regularly regarding HZ inter alia for at least 24 months following ASCT. Since 01/2015 patients received prophylactic low-dose acyclovir (400 mg per day) during the first 12 months following discharge after ASCT (n=107).

RESULTS

Twenty percent of patients without this kind of prophylaxis and 2.8% of patients with prophylaxis developed HZ (p<0.001). No patient with this prophylaxis developed HZ in the first year after ASCT, 2.8% of patients in the second year after ASCT. A prognostic factor was the kind of diagnosis: 30% of lymphoma patients and 14% of myeloma patients developed HZ in the first 24 months after ASCT without prophylaxis, but only 6.3% and 0% of patients with prophylaxis, respectively. Neither an increase of HZ cases following prophylaxis nor acyclovir refractory HZ cases were observed.

CONCLUSIONS

Zoster prophylaxis with low-dose acyclovir over 12 months after ASCT is effective and well tolerated. This article is protected by copyright. All rights reserved.

Varicella Zoster Virus Infection in Children with Autologous Hematopoietic Cell Transplantation: A Retrospective, Single-Center Study in Korea

Although long-term antiviral prophylaxis is recommended to prevent varicella zoster virus (VZV) infection in seropositive recipients of allogeneic and autologous (auto-) hematopoietic cell transplantation (HCT), studies of VZV infections in pediatric auto-HCT recipients are rare. This study aimed to investigate the incidence and characteristics of VZV infection in pediatric auto-HCT recipients and explore the risk factors of VZV infection and its effect on survival outcomes. This study included all pediatric patients who underwent auto-HCT at Samsung Medical Center, Seoul, Korea, between January 1998 and December 2013. Before 2006, short-term acyclovir prophylaxis was provided until neutrophil engraftment; thereafter, routine prophylaxis was not provided. Patients who developed either herpes zoster or chickenpox within 2 years from transplantation were identified, and a chart review was performed. A total of 413 recipients and 698 auto-HCTs were included. Sixty-one episodes of VZV infections were identified in 54 patients. Fourteen cases of VZV infection (23%; 14 of 61) occurred within 30 days after auto-HCT. The cumulative incidence of the first episode of VZV infection at 2 years after transplantation was 14% (95% confidence interval [CI], 7.9% to 22.8%) in all recipients and 9% (95% CI, 1.0 to 26.6) in VZV-seronegative patients. Notably, the VZV infection rate increased with age and the VZV infection rate in patients age 15 to 19 years was almost three times higher than in patients age 0 to 4 years (28% versus 10%; P = .003). However, there was no difference in the VZV infection rate between recipients of single auto-HCT and recipients of tandem auto-HCT. Two patients died of disseminated VZV infection. VZV infection is a considerable risk in auto-HCT recipients with or without short-term prophylaxis. Universal antiviral prophylaxis might be considered, particularly in older children, regardless of VZV serologic results. To our knowledge, this is the largest study of VZV infection in pediatric auto-HCT recipients reported to date.

Herpes zoster incidence and cost in patients receiving autologous hematopoietic stem-cell transplant

OBJECTIVE

Among patients receiving autologous hematopoietic stem cell transplant (Auto-HSCT), this study estimated the incidence of herpes zoster (HZ), compared healthcare costs among patients with and without HZ, and evaluated antiviral prophylaxis (AP) use.

RESEARCH DESIGN AND METHODS

A retrospective study was conducted using data from a large health plan to identify patients ≥18 years with ≥1 claim for an Auto-HSCT procedure during 2006-2011 (n = 2,530). Patients were followed from date of Auto-HSCT until risk-end date, defined as development of HZ, end of enrollment, death, or December 31, 2011. HZ incidence was calculated as cases observed after Auto-HSCT, divided by accrued time-at-risk in person-years (PY). AP use and duration were defined by prescription fills. One-year medical and pharmacy costs were calculated as combined health plan and patient paid amounts.

MAIN OUTCOME MEASURES

HZ incidence and healthcare costs were calculated using administrative claims data.

RESULTS

Overall HZ incidence was 62.2/1,000 PY (95% CI = 54.3-70.9). Most (72.3%) patients were prescribed AP. During the first 90-days post-Auto-HSCT, patients without AP had increased incidence (151.6/1,000 PY, 95% CI = 88.3-242.6) compared to those prescribed AP pre- (30.9/1,000 PY, 95% CI = 11.3-67.2) or post-Auto-HSCT (33.0/1,000 PY, 95% CI = 13.3-67.9). Total adjusted mean 1-year all-cause healthcare costs were $74,875 for patients who developed HZ and $70,279 for patients who did not (difference = $4,596 (cost ratio = 1.07, 95% CI = 0.86-1.32, p = .566)).

CONCLUSIONS

HZ incidence was high, despite AP use. Mean annual healthcare costs were higher for patients with HZ, but the difference was not statistically significant. An effective vaccine against HZ could be useful in decreasing both incidence of and cost for HZ in this population.

Herpes Zoster in Autologous Hematopoietic Cell Transplant Recipients in the Era of Acyclovir or Valacyclovir Prophylaxis and Novel Treatment and Maintenance Therapies

The epidemiology of herpes zoster (HZ) in contemporary autologous hematopoietic cell transplant (HCT) recipients, and the impact of acyclovir (ACV)/valacyclovir (VACV) prophylaxis, is not well described. In this observational study from 2002 to 2010, we retrospectively identified 1000 varicella zoster virus (VZV)-seropositive autologous HCT recipients with up to 5 years of follow-up. The incidence of HZ and use of ACV/VACV prophylaxis were determined through review of medical records and mailed questionnaires. Risk factors for HZ were determined by multivariable Cox regression. Over a period of 5 years after autologous HCT, 194 patients developed at least 1 HZ episode, with a cumulative incidence of 21%; 159 of 194 (82%) were not on prophylaxis at the time of HZ. A second episode of HZ occurred in 31 of 194 (16%) patients. Patients taking ACV/VACV had reduced risk for HZ (adjusted hazard ratio [aHR], .59; 95% confidence interval [CI], .37 to .91), whereas those older than the median age (≥55.5 years) had increased risk (aHR, 1.42; 95% CI, 1.05 to 1.9). Disseminated VZV was reported in 8% and postherpetic neuralgia in 13% of patients. We demonstrate a high burden of HZ late after autologous HCT, despite long-term antiviral prophylaxis. Improved prevention strategies are needed to provide sustained protection against HZ after autologous HCT.

Predicting risk factors for varicella zoster virus infection and postherpetic neuralgia after hematopoietic cell transplantation using ordered logistic regression analysis

To identify risk factors for varicella zoster virus (VZV) infection and postherpetic neuralgia (PHN) after hematopoietic cell transplantation (HCT), we conducted a retrospective chart review of 163 consecutive patients who underwent HCT between November 2004 and July 2014. Overall, the male/female (M/F) ratio was 80/83, median age at HCT was 54 (range 15-69) years, and autologous/allogeneic HCT (auto/allo-HCT) ratio was 71/92. Forty-four patients [M/F, 25/19; median age, 57 (range: 16-68) years; auto/allo-HCT, 26/18] developed VZV infection after HCT. All cases were successfully treated with acyclovir (ACV) or valacyclovir, and there was no VZV-related death. Nine (20%) of the 44 patients [M/F, 5/4; median age, 58 (range: 21-63) years; auto/allo-HCT, 7/2] developed PHN after resolution of zoster. Multivariate ordered logistic analysis identified receiving immunosuppressive therapy at the cessation of ACV [odds ratio (OR) = 74.53; 95% confidence interval (CI) = 6.99-794.32; P = 0.0004] as a risk factor for VZV infection and PHN in allo-HCT recipients. However, in auto-HCT recipients, only advanced age was identified as a risk factor (OR = 1.06, 95% CI = 1.002-1.127, P = 0.0429). Our findings indicate receiving immunosuppressive therapy at the cessation of ACV is a significant risk factor for allo-HCT recipients, while advanced age is a significant risk factor for auto-HCT recipients.