[Epidemiology of febrile neutropenia in patients with hematological disease-a prospective multicentre survey in China]

Clinical and diagnostic values of metagenomic next-generation sequencing for infection in hematology patients: a systematic review and meta-analysis

OBJECTIVES

This meta-analysis focused on systematically assessing the clinical value of mNGS for infection in hematology patients.

METHODS

We searched for studies that assessed the clinical value of mNGS for infection in hematology patients published in Embase, PubMed, Cochrane Library, Web of Science, and CNKI from inception to August 30, 2023. We compared the detection positive rate of pathogen for mNGS and conventional microbiological tests (CMTs). The diagnostic metrics, antibiotic adjustment rate and treatment effective rate were combined.

RESULTS

Twenty-two studies with 2325 patients were included. The positive rate of mNGS was higher than that of CMT (blood: 71.64% vs. 24.82%, P < 0.001; BALF: 89.86% vs. 20.78%, P < 0.001; mixed specimens: 82.02% vs. 28.12%, P < 0.001). The pooled sensitivity and specificity were 87% (95%CI: 81-91%) and 59% (95%CI: 43-72%), respectively. The reference standard/neutropenia and research type/reference standard may be sources of heterogeneity in sensitivity and specificity, respectively. The pooled antibiotic adjustment rate according to mNGS was 49.6% (95% CI: 41.8-57.4%), and the pooled effective rate was 80.9% (95% CI: 62.4-99.3%).

CONCLUSION

mNGS has high positive detection rates in hematology patients. mNGS can guide clinical antibiotic adjustments and improve prognosis, especially in China.

Development of a Risk Prediction Model of Subsequent Bloodstream Infection After Carbapenem-Resistant Enterobacteriaceae Isolated from Perianal Swabs in Hematological Patients

Purpose

Patients with hematological diseases are at high risk of carbapenem-resistant Enterobacteriaceae (CRE) infection, and CRE-related bloodstream infection (BSI) is associated with high mortality risk. Therefore, developing a predictive risk model for subsequent BSI in hematological patients with CRE isolated from perianal swabs could be used to guide preventive strategies.

Methods

This was a single-center retrospective cohort study at a tertiary blood diseases hospital, including all hematological patients hospitalized from 10 October 2017 to 31 July 2021. We developed a predictive model using multivariable logistic regression and internally validated it using enhanced bootstrap resampling.

Results

Of 421 included patients with CRE isolated from perianal swabs, BSI due to CRE occurred in 59. According to the multivariate logistic analysis, age (OR[odds ratio]=1.04, 95% CI[confidence interval]: 1.01-1.06, P=0.004), both meropenem and imipenem minimal inhibitory concentration (MIC) of the isolate from perianal swabs>8ug/mL (OR=5.34, 95% CI: 2.63-11.5, P<0.001), gastrointestinal symptoms (OR=3.67, 95% CI: 1.82-7.58, P<0.001), valley absolute neutrophil count (10⁹/L)>0.025 (OR=0.07, 95% CI: (0.02-0.19, P<0.001) and shaking chills at peak temperature (OR=6.94, 95% CI: (2.60-19.2, P<0.001) were independently associated with CRE BSI within 30 days and included in the prediction model. At a cut-off of prediction probability ≥ 21.5% the model exhibited a sensitivity, specificity, positive predictive value and negative predictive value of 79.7%, 85.6%, 96.27% and 47.47%. The discrimination and calibration of the prediction model were good on the derivation data (C-statistics=0.8898; Brier score=0.079) and enhanced bootstrapped validation dataset (adjusted C-statistics=0.881; adjusted Brier score=0.083). The risk prediction model is freely available as a mobile application at https://liujia1992.shinyapps.io/dynnomapp/.

Conclusion

A prediction model based on age, meropenem and imipenem MIC of isolate, gastrointestinal symptoms, valley absolute neutrophil count and shaking chills may be used to better inform interventions in hematological patients with CRE isolated from perianal swabs.

[Clinical application value of peripheral blood metagenomic next-generation sequencing test for patients with hematological diseases accompanied by fever]

Objective: To investigate the clinical application value of peripheral blood metagenomic next-generation sequencing (mNGS) test for patients with hematological diseases accompanied by fever. Methods: The blood mNGS results and clinical data of inpatients with hematological diseases accompanied by fever treated in the Hematology Department of Tianjin Medical University General Hospital in March 2020 to June 2021were retrospectively analyzed. A total of 90 patients with 98 cases of specimens were included. The pathogen distribution characteristics and mNGS test performance were analyzed. Results: The positive rate of peripheral blood mNGS was significantly higher than that of traditional examination (68.37% vs 37.76%, P<0.001) and blood culture (68.37% vs 9.18%, P<0.001) . Viral, bacterial, and fungal infections accounted for 38.81%, 14.93%, and 2.99% in patients with single-pathogen infections, respectively. Polymicrobial infections accounted for 43.28%, in which viral and bacterial coinfections were the most common type (25.37%) . There were 55 virus-positive cases (82.09%) , 30 bacteria-positive cases (44.78%) , and 14 fungus-positive cases (20.90%) . The clinical approval rate of peripheral blood mNGS was 64.63% (63/98) . The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of peripheral blood mNGS were 75.68%, 36.07%, 41.79%, and 70.97%, respectively, and the overall consistency rate with traditional examination was 51.02%. Of the 22 pulmonary infection cases with no detectable pathogens by conventional tests, the pathogens were identified by peripheral blood mNGS in 14 cases, 10 of which were clinically approved. Conclusion: The positive rate of peripheral blood mNGS was significantly higher than that of blood culture and traditional laboratory examination. Peripheral blood mNGS had a high clinical recognition rate, sensitivity, and NPV in the detection of pathogens in patients with hematological diseases accompanied by fever.

[Application value of metagenomic next-generation sequencing for pathogen detection in childhood agranulocytosis with fever]

OBJECTIVES

To study the application value of metagenomic next-generation sequencing (mNGS) for pathogen detection in childhood agranulocytosis with fever.

METHODS

A retrospective analysis was performed on the mNGS results of pathogen detection of 116 children with agranulocytosis with fever who were treated from January 2020 to December 2021. Among these children, 38 children with negative mNGS results were enrolled as the negative group, and 78 children with positive results were divided into a bacteria group (n=22), a fungal group (n=23), and a viral group (n=31). Clinical data were compared between groups.

RESULTS

For the 116 children with agranulocytosis and fever, the median age was 8 years at diagnosis, the median turnaround time of mNGS results was 2 days, and the positive rate of mNGS testing was 67.2% (78/116). Compared with the negative group, the bacterial group had a higher procalcitonin level (P<0.05), the fungal group had higher level of C-reactive protein and positive rate of (1,3)-β-D glucan test/galactomannan test (P<0.05), and the fungal group had a longer duration of fever (P<0.05). Among the 22 positive microbial culture specimens, 9 (41%) were consistent with the mNGS results. Among the 17 positive blood culture specimens, 8 (47%) were consistent with the mNGS results. Treatment was adjusted for 28 children (36%) with the mNGS results, among whom 26 were cured and discharged.

CONCLUSIONS

The mNGS technique has a shorter turnaround time and a higher sensitivity for pathogen detection and can provide evidence for the pathogenic diagnosis of children with agranulocytosis and fever.

[Analysing pathogenic bacterial spectrum and drug resistance of bloodstream infection in patients with allogeneic hematopoietic stem cell transplantation]

Objective: To elucidate the clinical characteristics of bloodstream infection in patients with allogeneic hematopoietic stem cell transplantation (allo-HSCT) in our hospital and improves the survival of transplant patients with bloodstream infection. Methods: Two hundred and ten patients with allo-HSCT from the Department of Hematology were retrospectively analyzed between October 2014 and September 2019. Pathogen distribution, drug resistance, risk factors, and outcomes were investigated in 49 allo-HSCT patients with bloodstream infections. Results: Forty-nine of 210 patients with allo-HSCT had bloodstream infection, and 59 pathogenic microorganisms were identified, mainly Gram-negative bacteria (67.8%) , of which E. coli had the highest incidence (23.7%) , CRO accounted for 42.5%, and Grampositive bacteria accounted for 23.7% (without vancomycin or linezolid-resistant strain) . Additionally, fungi accounted for 8.5%. Univariate analysis suggested that the risk factors of bloodstream infection were gender, pretransplant disease status, and conditioning regimen. In contrast, multivariate analysis showed that bloodstream infection was mainly related to conditioning regimens. Further grouping results showed that 77.6% of patients with neutropenia had bloodstream infections, and 22.4% of patients with non-neutropenia had bloodstream infections; 81.0% of patients with active infections before transplantation had bloodstream infections, while bloodstream infection occurred in 16.9% of patients without active infection. Survival analysis showed that long-term survival of patients with bloodstream infection is shorter than that of patients without bloodstream infection and long-term survival of patients with CRO infection is shorter than that of patients without CRO infection. The survival of patients with neutropenia longer than 14 d is shorter than that of patients with neutropenia shorter than 14 d. Furthermore, there is no correlation between whether there is an active infection before transplantation and whether they are in a neutropenic state at the time of infection and survival. Conclusion: Our results suggest that effective prevention of bloodstream infections from drug-resistant bacteria, particularly CRO, shortening the duration of neutropenia, eradication of potential infections before transplantation, and patient-adaptive conditioning could reduce transplant-related mortality and improve prognosis.

Clinical factors predictive of mortality in acute leukemia patients with febrile neutropenia

BACKGROUND

Acute leukemia is mainly treated with chemotherapy leading to febrile neutropenia (FN). There is limited data on clinical factors predictive of mortality in adults with acute leukemia and FN.

METHODS

This was a retrospective cohort study and enrolled adult patients, diagnosed as acute leukemia, and developed FN. The eligible patients were admitted and followed up with mortality as the primary outcome. A stepwise, multivariate logistic regression analysis was used to find predictors for mortality.

RESULTS

There were 203 patients met the study criteria. Of those, 14 patients died (6.89%). AML was the most common type of acute leukemia with FN (64.04%). There were five remaining factors in the final model: AML, FN at admission, prolong broad spectrum antibiotics, lower respiratory tract infection, and Aspergillosis. Only lower respiratory tract infection was significant with adjusted odds ratio of 7.794 (95% CI of 1.549, 39.212). The Hosmer-Lemeshow Chi square was 2.74 (p value 0.907). The lower respiratory tract infection group had higher proportions of Gram negative and fungus than the non-lower respiratory tract infection group; specifically E. coli (p 0.003), and Aspergillus (P < 0.001).

CONCLUSIONS

There were two independent predictors of mortality in acute leukemia patients with FN: septic shock and lower respiratory tract infection regardless of leukemia type or pathogen. E. coli and Aspergillus were more common in those with lower respiratory tract infection than those without. No specific pathogens were found in cases of septic shock.

[Epidemiological analysis of pathogens causing bloodstream infections in department of hematology in Guangdong Province]

Objective: To evaluate the epidemiology of bacterial bloodstream infections in patients submitted to hematologic wards in southern China. Methods: A total of 50 teaching hospitals were involved based on the China Antimicrobial Resistance Surveillance System. The data of clinical isolates from blood samples were collected from January 1, 2019, to December 31, 2019. Antimicrobial susceptibility testing was conducted by the Kirby-Bauer automated systems, and the results were interpreted using the CLSI criteria. Results: The data of 1,618 strains isolated from hematologic wards in 2019 were analyzed, of which gram-negative bacilli and gram-positive cocci accounted for 71.8% and 28.2%, respectively. Of those, the five major species were most often isolated, including Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, coagulase-negative staphylococcus, and Streptococcus viridans. The prevalence rates of methicillin-resistant strains in Staphylococcus aureus and coagulase-negative staphylococcus were 19.7% and 80.6%, respectively. No gram-positive cocci were resistant to vancomycin, linezolid, and teicoplanin, and none of the enterococci were resistant to linezolid. The resistance rate of S. viridans to penicillin G was 6.9%, and those to ceftriaxone and cefotaxime were more than 25%. The resistance rate of E. coli and K. pneumoniae in Enterobacteriaceae was higher in children than that in adults. The resistance rate of K. pneumoniae to meropenem was 14.1%. The resistant rate of Enterobacter cloacae to carbapenem was more than 25%. P. aeruginosa was more sensitive to more antibiotics than 80%, but the resistance rate to meropenem in children was higher than that in adults (11.8% vs. 6.5%). The proportion of gram-positive cocci in the ICU and respiratory departments was higher than that in the hematology department. The detection rates of carbapenem-resistant E. coli and K. pneumoniae in the respiratory department were the lowest with 0.3% and 3.7%, respectively, while those of CRPA and CRAB in the hematology department were the lowest with 8.3% and 25.8%, respectively. The detection rate of all carbapenem-resistant organisms in the ICU was the highest among the three departments. Conclusion: The etiology and drug resistance of bacteria from blood samples in the hematology department are different from those in the ICU and respiratory departments. The proportions of K. pneumoniae, P. aeruginosa, E. cloacae, and S. viridans dominating in the department of Hematology were significantly higher than those in the ICU and respiratory departments in Guangdong region.

[Clinical features and laboratory data analysis of Aeromonas bacteremia with hematological diseases]

目的

分析患有血液系统疾病患者气单胞菌血流感染的临床及实验室特征，为该类患者气单胞菌感染的防治提供依据。

方法

回顾性分析中国医学科学院血液病医院2014年1月至2018年12月5年发生气单胞菌血症的血液系统疾病患者，收集患者临床感染特征、菌株耐药性、发生季节、治疗及转归情况等相关信息。

结果

共42例血液病患者发生气单胞菌血流感染，其中39例（92.9%）血流感染发生于粒细胞缺乏（粒缺）期，平均发热时间为4（1~27）d，22例（52.4%）患者症状仅为发热，6例（14.3%）伴消化道症状（腹痛、腹泻、恶心、上消化道出血），8例（19.0%）伴肺部感染，13例（31.0%）伴皮肤软组织感染。7例（16.7%）患者死亡，且均伴皮肤软组织感染。气单胞菌对碳青霉烯类抗菌药物的耐药率为68.3%~70.7%，而对头孢菌素类、喹诺酮类及氨基糖苷类抗菌药物的耐药率均小于10%。

结论

血液系统疾病合并气单胞菌血流感染主要发生在粒缺期，主要以发热为主，当伴有皮肤软组织感染时死亡率高。抗菌药物选择应依据药敏结果，避免使用碳青霉烯类抗菌药物。

Positive stool culture could predict the clinical outcomes of haploidentical hematopoietic stem cell transplantation

We aimed to identify the effect of positive stool cultures (PSCs) on the clinical outcomes of patients undergoing haploidentical hematopoietic stem cell transplantation (haplo-HSCT) (n = 332). PSCs were observed in 61 patients (PSC group, 18.4%). Enterobacteriaceae in stool specimens was associated with a higher risk of bloodstream infection, and Candida in stool specimens was related to a higher risk of platelet engraftment failure. The cumulative incidence of infection-related mortality 1 year after haplo-HSCT in the PSC group was higher than that of the patients who showed persistently negative stool cultures (NSC group; 19.2% vs. 8.9%, P = 0.017). The probabilities of overall survival (71.4% vs. 83.8%, P = 0.031) and disease-free survival (69.6% vs. 81.0%, P = 0.048) 1 year after haplo-HSCT for the PSC group were significantly lower than those for the NSC group, particularly for patients who had Candida in their stool specimens. In multivariate analysis, Candida in stool specimens significantly increased the risk of mortality and was associated with poorer survival. Our results showed that PSC influenced the clinical outcomes after haplo-HSCT, particularly those who had Candida in their stool specimens.

[Impact of duration of antibiotic therapy on the prognosis of patients with acute myeloid leukemia who had Gram-negative bloodstream infection in consolidation chemotherapy]

目的

分析巩固化疗期间伴发革兰阴性菌（G⁻菌）血流感染的急性髓系白血病（AML）患者抗感染疗程对感染转归的影响。

方法

回顾性分析2010年9月至2016年1月入组“依据危险度分层对急性髓系白血病优化治疗的研究”临床试验的591例AML（非急性早幼粒细胞白血病）患者的血流感染资料，将其中巩固化疗期间发生G⁻菌血流感染且持续发热时间<7 d的114例次血流感染（89例患者）纳入研究，分析抗感染疗程对感染转归的影响。

结果

114例次血流感染发生时，患者中位ANC为0（0~5.62）×10⁹/L，中性粒细胞缺乏（粒缺）持续的中位时间为9（3~26）d，抗感染治疗的中位时间为7（4~14）d。抗感染疗程≤7 d与>7 d组比较，停药后3 d内再发热比例、再次发生相同菌株血流感染比例分别为1.2%对3.0%、18.5%对21.2%，差异均无统计学意义（P=0.522，OR=0.400，95%CI 0.024~6.591；P=0.741，OR=0.844，95%CI 0.309~2.307）。同时，两组患者均未发生7 d及30 d内感染相关死亡。且倾向性评分平衡患者特征及用药差异因素后，抗感染疗程≤7 d较>7 d组再次发生相同菌株血流感染比例仍无明显增高（P=0.525，OR=0.663，95%CI 0.187~2.352）。

结论

对于巩固化疗期间伴发G⁻菌血流感染的AML患者，若发热时间<7 d，敏感抗菌药物治疗7 d后停药并不增加停药后3 d内再发热，粒缺期再次出现相同菌株血流感染及感染相关7 d、30 d内死亡风险。提示短疗程抗感染方案可以成为巩固化疗伴发G⁻菌血流感染AML患者感染控制情况下合理的治疗选择。

[Perianal swabs surveillance cultures of Carbapenem-resistant Enterobacteriaceae(CRE) can be hints for CRE bloodstream infection in patients with hematological diseases]

目的

探讨血液病患者肛周皮肤拭子细菌培养检出耐碳青霉烯类肠杆菌（CRE）对CRE血流感染的预警价值，寻找CRE血流感染的危险因素。

方法

对2016年1月至2017年12月进行肛周皮肤拭子细菌培养的血液病患者分离出CRE的耐药率、患者后期CRE血流感染发生情况及危险因素进行回顾性分析。

结果

2 914例血液病患者进行了肛周皮肤拭子细菌培养，74例检出CRE，其中后期发生CRE血流感染者13例（17.6%）。共分离出CRE 87株（相同患者相同部位去重），包括肺炎克雷伯菌31株、大肠埃希菌43株、阴沟肠杆菌8株、其他肠杆菌科细菌6株。分离出CRE菌株对哌拉西林/他唑巴坦、亚胺培南、美罗培南、阿米卡星、左氧氟沙星、替加环素的耐药率分别为91.9%、74.4%、98.8%、17.6%、74.4%和8.0%。13例发生CRE血流感染患者肛周皮肤拭子与血液中分离株对碳青霉烯类、氨基糖苷类、喹诺酮类及替加环素耐药程度一致率较高。粒细胞缺乏（粒缺）、存在消化道症状、肛周感染持续时间为肛周皮肤CRE阳性患者发生CRE血流感染的独立危险因素（OR值分别为1.10、1.13和1.23，P值分别为0.029、0.005、0.016）。

结论

对血液病患者进行肛周皮肤拭子细菌培养可为后期CRE血流感染提供预警，并可为其提供抗菌药物选择参考；粒缺、伴消化道症状以及肛周感染持续时间长可作为CRE血流感染患者早期识别因素。

[A multicenter, retrospective study of pathogenic bacteria distribution and drug resistance in febrile neutropenic patients with hematological diseases in Shanghai]

目的

了解上海地区中性粒细胞缺乏（粒缺）伴发热血液病患者致病细菌的分布及耐药情况。

方法

回顾性分析2012年1月至2014年12月上海市12家医院血液科粒缺伴发热住院患者的临床分离菌株，用纸片扩散法进行药敏试验，WHONET 5.6软件分析病原菌分布及药敏数据。

结果

从上海地区粒缺伴发热患者中共分离出1 260株细菌，其中革兰阳性菌420株（33.3%），革兰阴性菌840株（66.7%）。排在前七位的分别是肺炎克雷伯菌158株（12.5%）、嗜麦芽窄食单胞菌120株（9.5%）、大肠埃希菌115株（9.1%）、铜绿假单胞菌109株（8.7%）、鲍曼不动杆菌83株（6.6%）、金黄色葡萄球菌70株（5.6%）和屎肠球菌63株（5.0%）。呼吸道分泌物标本中，非发酵菌占56.2%（350/623）。其中嗜麦芽窄食单胞菌占15.3%（95/623）。血液标本中，肠杆菌科细菌占42.3%（104/246），凝固酶阴性葡萄球菌占34.6%（85/246）。脓液标本中肠杆菌科细菌占39.4%（76/193），肠球菌属细菌占28.5%（55/193）。耐甲氧西林金黄色葡萄球菌葡萄球菌（MRSA）和耐甲氧西林凝固酶阴性葡萄球菌（MRCNS）的检出率分别为54.3%和82.5%，未发现耐利奈唑胺、万古霉素、替考拉宁葡萄球菌属菌株，耐万古霉素屎肠球菌的检出率为8.9%，肠球菌属未检出耐利奈唑胺的菌株。肠杆菌科细菌对碳青霉烯类药物高度敏感。铜绿假单胞菌对亚胺培南和美罗培南的耐药率已分别达34.1%和15.8%。嗜麦芽窄食单胞菌对米诺环素、左氧氟沙星、复方磺胺甲恶唑等药物敏感。鲍曼不动杆菌仅对头孢哌酮/舒巴坦的耐药率低于10.0%。肺炎克雷伯菌、嗜麦芽窄食单胞菌、铜绿假单胞菌、鲍曼不动杆菌等革兰阴性菌对大多常用抗菌药物的耐药率低于CHINET监测的数据。

结论

粒缺伴感染患者常见感染部位致病菌株分布有其特点，细菌耐药率整体低于CHINET全国医院大样本监测。

[Distribution and drug resistance of pathogens of blood stream infection in patients with hematological malignancies after chemotherapy]

Objective: To investigate the distribution and resistance of pathogens isolated from blood cultures in patients with hematological malignancies after chemotherapy in Union Hospital of Fujian Medical University so as to understand the real situation of blood stream infection (BSI) and provide the basis for rational use of antibiotics in clinic. Methods: The data of 657 strains isolated from blood culture specimens of patients with hematological malignancies from January 2013 to December 2016 were collected analyzed. Results: A total of 657 cases of blood culture positive bacterial strains were included in the study, involving 410 cases (62.4%) with single Gram-negative bacteria (G(-) bacteria) , 163 cases (24.8%) with single Gram-positive bacteria (G(+) bacteria) , 50 cases (7.6%) with single fungi. The most common 5 isolates in blood culture were Klebsiella pneumoniae (17.5%) , Escherichia coli (17.2%) , Coagulase negative staphylococci (CNS) (14.9%) , Pseudomonas aeruginosa (14.2%) and Staphylococcus aureus (3.5%) . The extended-spectrum beta-lactamase (ESBL) production rates of Klebsiella pneumoniae and Escherichia coli were 25.2% and 55.8%, respectively. ESBL producing strains were almost more resistant than non-ESBL producing strains. The resistance rates of Enterobacteriaceae to carbapenems, piperacillin/tazobactam and tigecycline were lower than 14.0%. The resistance rates of Pseudomonas aeruginosa to a variety of drugs were lower than 12.0%. Tigecycline-resistant Acinetobacter baumannii bacteria were not detected, and the resistance rates of Acinetobacter baumannii to cefixime and cefotaxime were 7.1%. Methicillin-resistant strains in CNS (MRCNS) and in Staphylococcus aureus (MRSA) accounted for 84.7% and 43.5%, respectively. Vancomycin, linezolid and tigecycline-resistant G(+) bacteria were not detected. Conclusion: The pathogens isolated from blood culture were widely distributed. Most of them were G(-) bacteria, and the resistance to antibiotics was quite common. Furhermore, vancomycin, linezolid and tigecycline can be chosen empirically to treat patiens who ar suspected to have G(+) bacterial BSI.

[Clinical and bacteriological analysis of lymphoid tissue neoplasms patients with bacteria bloodstream infections]

Objective: To investigate the clinical status of lymphoid tissue neoplasms patients with bacteria bloodstream infections, bacteriology and drug susceptibility results, and provide the basis for rational clinical anti-infection option. Methods: A retrospectively analysis of clinical data and bacterial susceptibility test results of patients with bacteria bloodstream infections from September 2010 to December 2014 was conducted. Results: A total of 134 cases including 107 patients with bloodstream infections were enrolled. 84 cases were male, 50 cases were female, the median age was 31 (12-71) years old. 112 cases were agranulocytosis, and 106 cases were severe agranulocytosis (ANC<0.1×10(9)/L) . 27 cases underwent hematopoietic stem cell transplantation, 100 cases received chemotherapy[33 cases with VD (I) CP±L (vincristine+daunorubicin/idarubicin + cyclophosphamide + prednison±asparaginasum) induction chemotherapy, 41 cases with intensive chemotherapy of Hyper-CVAD/MA or MA (mitoxantrone+cytarabine) , 26 cases with other chemotherapy regimens], and 7 cases were infected without chemotherapy. 10 patients discharged from hospital owing to treatment abandoning, 120 cases were cured through anti-infective therapy, 2 patients died of bacteria bloodstream infections, 1 patient died of sudden cardiac, and 1 patient died of GVHD after allogenic hematopoietic stem cell transplantation. A total of 144 strains were isolated, including 108 strains (75.0%) of Gram-negative bacteria and 36 strains (25.0%) of Gram-positive cocci. The susceptibility of Gram-negative bacteria to the carbapenems was 98.00%, and the adjustment treatment rate of carbapenems was 3.0%. The susceptibility of Gram-negative bacteria to the other antibiotics was 60.30%, and the adjustment treatment rate was 90.5%. The susceptibility of Grampositive cocci to the carbapenems was 49.3%, and to glycopeptides and linezolid was 100.0%. Comparing all patients'empirical use of antimicrobial agents with the drugs susceptibility results of blood cultures, 80.1% of the patients'initial drug selection was sensitive. Conclusion: The lymphoid neoplasms patients experienced bacteria bloodstream infections most often after receiving the chemotherapy regimens of treating acute lymphoblastic leukemia. The majority type of bacteria was Gram-negative bacteria. Drug susceptibility test showed that susceptibility of Gram-negative bacteria to the carbapenems was the highest, and the treatment adjustment rate was obviously lower. The susceptibility of Gram-positive cocci to glycopeptides and linezolid was high, and which could be applied to the patients with Gram-positive cocci sepsis on basis of susceptibility results in general.

[Incidence of blood stream infections of 1265 patients with hematopoietic stem cell transplantation and analysis of pathogenic bacteria]

目的

分析造血干细胞移植（HSCT）患者血流感染的发生率、病原菌分布及药敏情况，为临床血流感染的经验性治疗提供依据。

方法

对2013–2015年在苏州大学附属第一医院行HSCT的1 265例患者进行血流感染发生率、血培养阳性率、病原菌种类和耐药情况分析。

结果

1 265例HSCT患者中，有784例（61.98%）共发生1 422例次血流感染，464例（59.2%）患者处于粒细胞缺乏期（ANC<0.5×10⁹/L）。2013–2015年病原菌检出率逐年上升，总体为20.07%。检出的401株病原菌中，革兰阴性菌221株（55.1%），革兰阳性菌165株（41.2%），真菌15株（3.7%）。排名前三位为大肠埃希菌（16.0%）、表皮葡萄球菌（15.5%）和肺炎克雷伯菌（11.2%）；细菌耐药情况严峻，多重耐药的鲍曼不动杆菌和嗜麦芽窄食单胞菌比例分别为64.70%与63.64%，耐甲氧西林金黄色葡萄球菌（MRSA）比例为57.14%，均超过50.0%。耐万古霉素肠球菌（VRE）与耐碳青霉烯类抗生素肠杆菌科细菌（CRE）比例分别为14.29%、6.78%。革兰阴性菌中肠杆菌科细菌对三、四代头孢类药物耐药率较高，对碳青霉烯类抗生素耐药率较低（6.4%）。非发酵菌对抗菌药物耐药情况差别较大，对碳青霉烯类抗生素耐药率较高（47.8%）；葡萄球菌属菌株对万古霉素、替考拉宁和利奈唑胺的敏感率均为100.0%。

结论

HSCT患者血流感染发生率较高，病原菌仍以革兰阴性菌为主，非发酵菌的占比也较高，未检测到对万古霉素、替考拉宁和利奈唑胺耐药的葡萄球菌。

Perianal Infections in the Phase before Engraftment after Allogeneic Hematopoietic Stem Cell Transplantations: A Study of the Incidence, Risk Factors, and Clinical Outcomes

In this study, we aimed to investigate the incidence, risk factors, and clinical outcomes of perianal infections during the pre-engraftment phase after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Consecutive patients who underwent non-T-cell-depleted allo-HSCT at the Peking University Institute of Hematology from January 1 to December 31, 2016 were enrolled (n = 646). Ninety-nine patients were found to have perianal infections during the pre-engraftment phase, and 80 were found to have neutropenia on perianal infection diagnosis. The cumulative incidence of perianal infection during the pre-engraftment phase after allo-HSCT was 15.3%. A history of perianal infection (hazard ratio [HR] = 15.28, p < 0.001) or hemorrhoids before allo-HSCT (HR = 3.09, p = 0.001) was significantly associated with the new occurrence of perianal infection after allo-HSCT. All patients received empirical broad-spectrum antimicrobial therapies, and 97 were cured after treatment. The clinical outcomes at 100 days after allo-HSCT were comparable in patients with and without perianal infections. In summary, patients who had perianal infection or hemorrhoids before allo-HSCT had a higher risk of new occurrence of perianal infection after allo-HSCT. With appropriate treatment, perianal infection during the pre-engraftment phase did not influence the clinical outcomes.

Empirical antibiotics targeting gram-positive bacteria for the treatment of febrile neutropenic patients with cancer

BACKGROUND

The pattern of infections among neutropenic patients with cancer has shifted in the last decades to a predominance of gram-positive infections. Some of these gram-positive bacteria are increasingly resistant to beta-lactams and necessitate specific antibiotic treatment.

OBJECTIVES

To assess the effectiveness of empirical anti-gram-positive (antiGP) antibiotic treatment for febrile neutropenic patients with cancer in terms of mortality and treatment failure. To assess the rate of resistance development, further infections and adverse events associated with additional antiGP treatment.

SEARCH METHODS

For the review update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2017, Issue 2), MEDLINE (May 2012 to 2017), Embase (May 2012 to 2017), LILACS (2012 to 2017), conference proceedings, ClinicalTrials.gov trial registry, and the references of the included studies. We contacted the first authors of all included and potentially relevant trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing one antibiotic regimen versus the same regimen with the addition of an antiGP antibiotic for the treatment of febrile neutropenic patients with cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted all data. Risk ratios (RR) with 95% confidence intervals (CIs) were calculated. A random-effects model was used for all comparisons showing substantial heterogeneity (I2 > 50%). Outcomes were extracted by intention-to-treat and the analysis was patient-based whenever possible.

MAIN RESULTS

Fourteen trials and 2782 patients or episodes were included. Empirical antiGP antibiotics were tested at the onset of treatment in 12 studies, and for persistent fever in two studies. The antiGP treatment was a glycopeptide in nine trials. Eight studies were assessed in the overall mortality comparison and no significant difference was seen between the comparator arms, RR of 0.90 (95% CI 0.64 to 1.25; 8 studies, 1242 patients; moderate-quality data). Eleven trials assessed failure, including modifications as failures, while seven assessed overall failure disregarding treatment modifications. Failure with modifications was reduced, RR of 0.72 (95% CI 0.65 to 0.79; 11 studies, 2169 patients; very low-quality data), while overall failure was the same, RR of 1.00 (95% CI 0.79 to 1.27; 7 studies, 943 patients; low-quality data). Sensitivity analysis for allocation concealment and incomplete outcome data did not change the results. Failure among patients with gram-positive infections was reduced with antiGP treatment, RR of 0.56 (95% CI 0.38 to 0.84, 5 studies, 175 patients), although, mortality among these patients was not changed.Data regarding other patient subgroups likely to benefit from antiGP treatment were not available. Glycopeptides did not increase fungal superinfection rates and were associated with a reduction in documented gram-positive superinfections. Resistant colonisation was not documented in the studies.

AUTHORS' CONCLUSIONS

Based on very low- or low-quality evidence using the GRADE approach and overall low risk of bias, the current evidence shows that the empirical routine addition of antiGP treatment, namely glycopeptides, does not improve the outcomes of febrile neutropenic patients with cancer.