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Ford CD, Lopansri BK, Hunter BD, Asch J, Hoda D. Multiplexed Gastrointestinal PCR Panels for the Evaluation of Diarrhea in Hematopoietic Stem Cell Transplantation Recipients. Transplant Cell Ther 2024; 30:814.e1-814.e7. [PMID: 38768906 DOI: 10.1016/j.jtct.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/12/2024] [Accepted: 05/14/2024] [Indexed: 05/22/2024]
Abstract
Multiplexed gastrointestinal PCR panels (MGPPs) are frequently used to aid the diagnosis and management of diarrhea in hematopoietic stem cell transplantation (HCT) recipients. Many issues related to the optimal use of MGPPs in HCT patients remain to be clarified. We aimed to better define MGPP diagnostic and therapeutic stewardship in HCT recipients, including indications for and benefits of testing, optimal timing of tests, and interpretation of results. We retrieved 463 consecutive MGPPs ordered on 651 consecutive first HCT (312 allogeneic, 339 autologous) performed at our institution between June 2015 and June 2023. One hundred and sixteen of the 463 MGPPs (25%) identified at least 1 diarrheagenic pathogen, and 12 (3%) identified more than 1 diarrheagenic pathogen. A positive result was more likely if the test was ordered within 48 hours of a hospital admission (41%; 32 of 78) or as an outpatient (41%; 46 of 111) compared with evaluation of hospital-onset diarrhea (14%; 38 of 274). Among the positive results, the most frequent pathogens identified included Clostridioides difficile (64%), diarrheagenic Escherichia coli (20%), norovirus (9%), and adenovirus 40/41 (5%). Thirty-eight percent of the positive C. difficile MGPP determinations were associated with a positive test for toxin. In our allogeneic HCT cohort, 3% of MGPPs for hospital-onset diarrhea yielded an organism other than C. difficile. Fifty-six percent of positive and 14% of all submitted tests resulted in a change in treatment. For organisms other than C. difficile, only 1% of all tests and 5% of positive tests resulted in initiation of therapy. For patients at risk for acute graft-versus-host disease (aGVHD), a positive or negative MGPP result was not predictive of a new diagnosis of aGVHD in proximity to diarrhea onset. These results suggest that MGPP testing is most useful when performed at hospital admission or on an outpatient basis. Because MGPPs are sensitive and do not distinguish between colonization and causes of diarrhea, caution is needed when interpreting results, especially for toxin-negative C. difficile and diarrheagenic gram-negative organisms.
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Affiliation(s)
- Clyde D Ford
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah.
| | - Bert K Lopansri
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Health, Salt Lake City, Utah; Department of Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, Utah
| | - Bradley D Hunter
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah
| | - Julie Asch
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah
| | - Daanish Hoda
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah
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Tao Y, Luo CJ, Zhang BH, Shen XY, Zhao RK, Ma BY, Shen N, Luo CY, Wang JM, Xia YJ, Xie L, Chen J, Mo X. Diagnostic performance of a multiplexed gastrointestinal PCR panel for identifying diarrheal pathogens in children undergoing hematopoietic stem cell transplant. World J Pediatr 2024:10.1007/s12519-023-00776-w. [PMID: 38367140 DOI: 10.1007/s12519-023-00776-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/24/2023] [Indexed: 02/19/2024]
Abstract
BACKGROUND Diarrhea is a common complication of hematopoietic stem cell transplantation (HSCT) and is associated with substantial morbidity, but its etiology is often unknown. Etiologies of diarrhea in this population include infectious causes, chemotherapy- or medication-induced mucosal injury and graft-versus-host disease (GVHD). Distinguishing these potential causes of diarrhea is challenging since diarrheal symptoms are often multifactorial, and the etiologies often overlap in transplant patients. The objectives of this study were to evaluate whether the FilmArray gastrointestinal (GI) panel would increase diagnostic yield and the degree to which pre-transplantation colonization predicts post-transplantation infection. METHODS From November 2019 to February 2021, a total of 158 patients undergoing HSCT were prospectively included in the study. Stool specimens were obtained from all HSCT recipients prior to conditioning therapy, 28 ± 7 days after transplantation and at any new episode of diarrhea. All stool samples were tested by the FilmArray GI panel and other clinical microbiological assays. RESULTS The primary cause of post-transplantation diarrhea was infection (57/84, 67.86%), followed by medication (38/84, 45.24%) and GVHD (21/84, 25.00%). Ninety-five of 158 patients were colonized with at least one gastrointestinal pathogen before conditioning therapy, and the incidence of infectious diarrhea was significantly higher in colonized patients (47/95, 49.47%) than in non-colonized patients (10/63, 15.87%) (P < 0.001). Fourteen of 19 (73.68%) patients who were initially colonized with norovirus pre-transplantation developed a post-transplantation norovirus infection. Twenty-four of 62 (38.71%) patients colonized with Clostridium difficile developed a diarrheal infection. In addition, FilmArray GI panel testing improved the diagnostic yield by almost twofold in our study (55/92, 59.78% vs. 30/92, 32.61%). CONCLUSIONS Our data show that more than half of pediatric patients who were admitted for HSCT were colonized with various gastrointestinal pathogens, and more than one-third of these pathogens were associated with post-transplantation diarrhea. In addition, the FilmArray GI panel can increase the detection rate of diarrheal pathogens in pediatric HSCT patients, but the panel needs to be optimized for pathogen species, and further studies assessing its clinical impact and cost-effectiveness in this specific patient population are also needed.
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Affiliation(s)
- Yue Tao
- Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Rd., Shanghai, 200127, China.
| | - Cheng-Juan Luo
- Department of Hematology and Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Rd., Shanghai, 200127, China
| | - Bing-Hua Zhang
- Department of Hematology and Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Rd., Shanghai, 200127, China
| | - Xin-Yan Shen
- Department of Hematology and Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Rd., Shanghai, 200127, China
| | - Rui-Ke Zhao
- Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Rd., Shanghai, 200127, China
| | - Bei-Ying Ma
- Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Rd., Shanghai, 200127, China
| | - Nan Shen
- Department of Infectious Diseases, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chang-Ying Luo
- Department of Hematology and Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Rd., Shanghai, 200127, China
| | - Jian-Min Wang
- Department of Hematology and Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Rd., Shanghai, 200127, China
| | - Yi-Jun Xia
- Medical Affairs, BioMérieux (Shanghai) Company, Limited, Shanghai, China
| | - Li Xie
- Clinical Research Institute, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Chen
- Department of Hematology and Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Rd., Shanghai, 200127, China.
| | - Xi Mo
- Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Rd., Shanghai, 200127, China.
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Yanamandra U, Khadwal A, Gupta S, Thomas T, Lad D, Taneja N, Prakash G, Varma N, Varma S, Malhotra P. Diarrheal woes in transplantation from real world settings with special focus on clostridium difficile infection. Med J Armed Forces India 2023; 79:679-683. [PMID: 37981921 PMCID: PMC10654365 DOI: 10.1016/j.mjafi.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/01/2023] [Indexed: 11/21/2023] Open
Abstract
Background Diarrhea is the major cause of discomfort and morbidity of patients undergoing hematopoietic stem cell transplant (HSCT). The cause of diarrhea may be infective or non-infective. Methods This is a prospective single center observational study from North India conducted over a period of approximately 4 years among 105 patients who underwent HSCT (autologous-72, allogeneic-33). The objective of the study was to identify the overall incidence and characteristics of diarrhea in HSCT in the real world, to evaluate any differences among allogeneic or autologous transplants, incidence of C Difficile among diarrheal patients, and antimicrobial usage among these patients. Results Diarrhea was present in 89 of 105 patients (84.7%). The mean diarrheal duration was of 8.39±4.57 days (range: 1-24 days). There was non statistical difference between the incidence of diarrhea amongst allogeneic and autologous transplants (78.9% Vs 87.5%). Out of 89 patients with diarrhea, 13 were CDTA positive. We could isolate Clostridium difficile in culture in only 7.6% of patients with CDTA positivity. Metronidazole was the antibiotic of choice for diarrhea in our post-transplant settings. Metronidazole was prescribed for a median duration of 8 days (Range: 3-18 days). Seventeen patients received oral vancomycin with a median duration of 8 days (Range: 5-14 days). Conclusion We conclude by saying that diarrhea was a common post-transplant morbidity. Clostridium difficile is not common in patients with the diarrhea post hematopoietic stem cell transplant. All cases of diarrhea need not be infective particularly in allogeneic settings.
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Affiliation(s)
- Uday Yanamandra
- Professor, Department of Medicine & Hematology, Armed Forces Medical College, Pune, India
| | - Alka Khadwal
- Professor (Hemat & BMT), Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Setu Gupta
- Resident, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Timmy Thomas
- Nursing Officer, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Deepesh Lad
- Associate Professor (Hemat & BMT), Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Neelam Taneja
- Professor (Microbiology), Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Gaurav Prakash
- Professor (Hemat & BMT), Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Neelam Varma
- Professor (Hematopath), Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Subhash Varma
- Professor (Hemat & BMT), Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Pankaj Malhotra
- Professor & Head (Medical Oncology & Clinical Hematology), Post Graduate Institute of Medical Education & Research, Chandigarh, India
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Haque E, Muhsen IN, Rasheed W, Fakih RE, Aljurf M. Parasitic infections in hematopoietic stem cell transplant recipients. Transpl Infect Dis 2023; 25 Suppl 1:e14160. [PMID: 37793057 DOI: 10.1111/tid.14160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/16/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Hematopoietic stem cell transplantation (HSCT) is a vital treatment for various hematological disorders. However, HSCT recipients face increased risks of infectious complications due to immunosuppression. Parasitic infections are a significant concern in this vulnerable population and can lead to substantial morbidity and mortality. This review examines parasitic infections in HSCT recipients, focusing on major infections affecting different organ systems, including intestinal parasites (Giardia spp., Entamoeba histolytica, and Cryptosporidium spp.), hematologic parasites (Plasmodium spp. and Babesia spp.), and tissue/visceral parasites (Toxoplasma gondii, Leishmania spp., and Trypanosoma cruzi). METHODS A systematic search of relevant literature was conducted and included studies up to August 2023. Databases included PubMed, Google Scholar, were queried using specific keywords related to parasitic infections in HSCT patients. The epidemiology, risk factors, clinical presentation, diagnostic methods, and treatment approaches for each infection were evaluated. RESULTS AND CONCLUSION Knowing the epidemiology, risk factors, and clinical presentations are crucial for timely intervention and successful management. By emphasizing early detection, effective therapies, and the unique challenges posed by each of these infections, this review highlights the importance of tailored strategies for HSCT recipients. Future research can further refine management protocols to enhance care and outcomes for these patients.
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Affiliation(s)
- Emaan Haque
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ibrahim N Muhsen
- Department of Medicine, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Walid Rasheed
- Department of Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Riad El Fakih
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mahmoud Aljurf
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Castillo Almeida NE, Cichon CJ, Gomez CA. How I approach diarrhea in hematological transplant patients: A practical tool. Transpl Infect Dis 2023; 25 Suppl 1:e14184. [PMID: 37910586 DOI: 10.1111/tid.14184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/05/2023] [Accepted: 10/15/2023] [Indexed: 11/03/2023]
Abstract
Diarrhea in hematopoietic stem-cell transplantation (HSCT) remains a multifactorial challenge that demands a nuanced diagnostic approach. The causes of infectious diarrhea in HSCT recipients are diverse and influenced by patient-specific risk factors, the post-transplant timeline, and local epidemiology. During the past decade, our understanding of diarrhea in HSCT has witnessed a transformative shift through the incorporation of gastrointestinal (GI) multiplex polymerase chain reaction (PCR) panels. However, the judicious application of these panels is imperative to avoid overtesting and prevent adverse outcomes. The challenge lies in distinguishing between the diverse causes of diarrhea, ascertaining the clinical significance of detected pathogens, and navigating the diagnostic uncertainty presented by several non-infectious conditions such as mucositis, intestinal dysbiosis, and acute graft-versus-host disease (aGvHD), all of which mimic infection. This review examines the landscape of infectious diarrhea in the HSCT population, encompassing both established (e.g., Cytomegalovirus, Clostridioides difficile, and norovirus) and emerging pathogens (e.g., sapoviruses, astroviruses). We propose a multifaceted diagnostic algorithm that combines clinical assessment, risk stratification, and tailored utilization of molecular platforms. While multiplex GI panels present invaluable opportunities for rapid and comprehensive pathogen detection, their judicious use is pivotal in preserving diagnostic stewardship. Customization of diagnostic algorithms tailored to local epidemiology ensures optimal patient care and resource utilization.
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Affiliation(s)
- Natalia E Castillo Almeida
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Catherine J Cichon
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Carlos A Gomez
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Mizutani Y, Kawamoto S, Takahashi M, Doi H, Wakida K, Tabuchi S, Tanda M, Soga A, Chijiki R, Takakura H, Kawaguchi K, Higashime A, Watanabe M, Ichikawa H, Matsumoto S, Sakai R, Goto H, Kurata K, Kakiuchi S, Miyata Y, Uryu K, Inui Y, Kitao A, Yakushijin K, Matsuoka H, Minami H. Efficacy and Safety of Synbiotics in Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation: A Randomized, Double-blinded, Placebo-controlled Pilot Study. Intern Med 2023; 62:2949-2958. [PMID: 36792187 PMCID: PMC10641206 DOI: 10.2169/internalmedicine.1314-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 12/26/2022] [Indexed: 02/16/2023] Open
Abstract
Objective High-dose chemotherapy with autologous hematopoietic stem cell transplantation (auto-HSCT) is an effective treatment option for relapsed and refractory aggressive malignant lymphoma. However, patients frequently experience treatment-induced gastrointestinal symptoms. Synbiotics, including live microorganisms and nondigestible food ingredients, reportedly ameliorate chemotherapy-induced mucosal damage. In this study, we assessed the efficacy and safety of synbiotics in patients undergoing auto-HSCT. Methods This randomized, double-blinded study included patients with malignant lymphoma eligible for auto-HSCT. The patients were randomly assigned to either a synbiotic group receiving Bifidobacterium longum (BB536) and guar gum or a placebo group receiving a placebo containing dextrin. The supplements were administered twice daily from the start of conditioning chemotherapy up to 28 days after auto-HSCT. The primary endpoint was the duration of total parenteral nutrition (TPN). Results In total, 12 patients were included and randomized. The median duration of TPN was 15 (range, 12-33) days in the synbiotic group and 17.5 (range, 0-32) days in the placebo group. The median duration of grade ≥3 diarrhea was shorter in the synbiotic group than in then placebo group (2.5 vs. 6.5 days), as was the duration of hospital stay (31.5 vs. 43 days). The oral intake and quality of life regarding diarrhea and anorexia improved in the synbiotic group after engraftment. Synbiotic infections, including bacteremia, were not observed. Conclusion Synbiotics may reduce gastrointestinal toxicity, thereby reducing nutritional problems and improving the quality of life of patients undergoing auto-HSCT, without severe adverse events.
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Affiliation(s)
- Yu Mizutani
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine and Hospital, Japan
| | - Shinichiro Kawamoto
- Department of Transfusion Medicine and Cell Therapy, Kobe University Hospital, Japan
| | | | - Hisayo Doi
- Division of Nursing, Kobe University Hospital, Japan
| | - Kumiko Wakida
- Division of Nutrition, Kobe University Hospital, Japan
| | | | - Masaaki Tanda
- Department of Pharmacy, Kobe University Hospital, Japan
| | - Akihiro Soga
- Department of Pharmacy, Kobe University Hospital, Japan
| | - Ruri Chijiki
- Department of Medical Oncology/Hematology, Kobe University Hospital, Japan
| | - Hidetomo Takakura
- Department of Medical Oncology/Hematology, Kobe University Hospital, Japan
| | - Koji Kawaguchi
- Department of Medical Oncology/Hematology, Kobe University Hospital, Japan
| | - Ako Higashime
- Department of Medical Oncology/Hematology, Kobe University Hospital, Japan
| | - Marika Watanabe
- Department of Medical Oncology/Hematology, Kobe University Hospital, Japan
| | - Hiroya Ichikawa
- Department of Medical Oncology/Hematology, Kobe University Hospital, Japan
| | - Sakuya Matsumoto
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine and Hospital, Japan
| | - Rina Sakai
- Department of Medical Oncology/Hematology, Kobe University Hospital, Japan
| | - Hideaki Goto
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine and Hospital, Japan
| | - Keiji Kurata
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine and Hospital, Japan
| | - Seiji Kakiuchi
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine and Hospital, Japan
| | - Yoshiharu Miyata
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine and Hospital, Japan
| | - Kiyoaki Uryu
- Department of Medical Oncology/Hematology, Kobe University Hospital, Japan
| | - Yumiko Inui
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine and Hospital, Japan
| | - Akihito Kitao
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine and Hospital, Japan
| | - Kimikazu Yakushijin
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine and Hospital, Japan
| | - Hiroshi Matsuoka
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine and Hospital, Japan
| | - Hironobu Minami
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine and Hospital, Japan
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Lin L, Hong M, Fu X. Mycophenolate mofetil increases the risk of diarrhea in allogeneic hematopoietic stem cell transplantation recipients. J Int Med Res 2023; 51:3000605231206968. [PMID: 37879636 PMCID: PMC10601400 DOI: 10.1177/03000605231206968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/22/2023] [Indexed: 10/27/2023] Open
Abstract
OBJECTIVES Mycophenolate mofetil (MMF) was reported to be a main cause of diarrhea following organ transplantation. However, research on MMF-induced diarrhea following allogeneic hematopoietic stem cell transplantation (allo-HSCT) is currently insufficient. This retrospective study examined the incidence of MMF-induced diarrhea among allo-HSCT recipients. METHODS Recipients were divided according to the receipt of MMF and the appearance of diarrhea. The differences in clinical information, MMF usage and trough concentrations, and the occurrence of diarrhea from the first day of conditioning treatment to 100 days after transplantation were analyzed. RESULTS In total, 32.9% of the recipients reported diarrhea. The incidence rate of diarrhea was higher in the MMF group than in the non-MMF group (40.0% vs. 16.7%). MMF-induced diarrhea usually occurred within 9 days of MMF initiation and persisted for 7.27 ± 3.54 days. The average body weight, MMF daily dose, and MMF trough concentration were higher in patients with diarrhea. CONCLUSION MMF increased the risk of diarrhea in allo-HSCT recipients, and the risk was related to the MMF dose and trough concentration. The difference in onset time could be a basis for identifying the cause of diarrhea in allo-HSCT recipients.
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Affiliation(s)
- Liangmo Lin
- Pharmacy Department, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China
| | - Mianhui Hong
- Pharmacy Department, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China
| | - Xiangjun Fu
- Hematological Department, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China
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Ford CD, Hoda D, Lopansri BK, Parra M, Sharma P, Asch J. An Algorithm Addressing the Problem of Overdiagnoses of Clostridioides difficile Infections in Hematopoietic Stem-Cell Transplant Recipients: Effects on CDI Rates and Patient Outcomes. Transplant Cell Ther 2023:S2666-6367(23)01242-3. [PMID: 37086852 DOI: 10.1016/j.jtct.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/13/2023] [Accepted: 04/16/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Diarrhea of other causes and Clostridioides difficile colonization are common in patients hospitalized for hematopoietic stem-cell transplants (HSCT). It has been well recognized that these issues tend to decrease the specificity of stool testing for C. difficile infection (CDI). The best way to address this problem is uncertain. OBJECTIVE In September 2018, we initiated a project with the goal of addressing the apparent problem of overdiagnosis of CDIs in our HSCT population. Using the quality improvement tool Model for Improvement we introduced a C. difficile stool testing and CDI diagnosis algorithm with the aim of decreasing unnecessary inpatient CDI diagnoses and treatments. In this study we examine the effects of the algorithm. STUDY DESIGN We reviewed all HSCT admissions for the 2 years before the algorithm introduction and the 3 years following recording all stool submissions for C. difficile determination and CDI. At the close of the study, we recruited our advanced practice providers (APPs) to review all CDI following algorithm initiation and provide feedback on the ease of use of the algorithm and potential improvements to the overall process. RESULTS Stool submissions for C. difficile determination decreased from 38.0 to 20.6/1000 inpatient days (p=<0.001) and CDI from 5.5 to 2.4/1000 days (p=0.007). Patients admitted for a first allogeneic-HSCT, a first autologous-HSCT, or an HSCT readmission showed similar proportionate reductions. No detrimental effects on length of stay, overall survival, progression free survival, rates of readmission following transplant, incidence of acute graft vs. host disease, or incidence of recurrent CDI were noted following algorithm introduction. A strategy of education, monitoring/feedback, and ease of algorithm access proved effective in inducing provider compliance. APPs rated the algorithm high on ease of use. CONCLUSIONS Use of an algorithm defining criteria for C. difficile testing, diagnosis, and treatment was associated with significantly decreased CDI diagnoses on a HSCT inpatient unit without apparent adverse effects.
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Affiliation(s)
- Clyde D Ford
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA.
| | - Daanish Hoda
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA
| | - Bert K Lopansri
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah 84143 USA; Department of Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, Utah 84105 USA
| | - Melissa Parra
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA
| | - Prashant Sharma
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA
| | - Julie Asch
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA
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9
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Guo J, Zhang H, Lu X, Xia L. Viable Bifidobacterium tablets for the prevention of chemotherapy-/radiation-induced mucositis in patients undergoing haematopoietic stem cell transplantation. Support Care Cancer 2023; 31:282. [PMID: 37074462 DOI: 10.1007/s00520-023-07755-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/13/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE Mucositis is a frequent and severe complication in haematopoietic stem cell transplantation (HSCT). The effectiveness of probiotics in mucositis has been indicated by several clinical trials, but the results are still controversial. To date, studies on the influence of probiotics in HSCT are limited. Therefore, we conducted this retrospective study to evaluate the impact of viable Bifidobacterium tablets on the incidence and duration of chemotherapy-/radiation-induced mucositis in patients undergoing HSCT. METHODS Clinical data of 278 patients who underwent HSCT between May 2020 and November 2021 were retrospectively analysed. They were divided into a control group (138) and a probiotic group (140) according to whether they took viable Bifidobacterium tablets. First, we analysed the baseline data of the two groups. Then, we compared the incidence, severity and duration of mucositis between the two groups by using Mann-Whitney U test, chi-square test and Fisher's exact test according to the type of data. In order to exclude the influence of confounding factors, we further evaluated the efficacy of oral probiotics in preventing oral mucositis by Binary logistic regression analysis. RESULTS The use of viable Bifidobacterium tablets markedly reduced the incidence of oral mucositis (OM) (62.9% vs. 81.2%, p = 0.001) and mainly reduced the incidence of grades 1-2 OM (74.6% vs. 58.6%, p = 0.005). There was no significant difference in the incidence of severe (grades 3-4) OM between the two groups (6.5% vs. 4.3%, p = 0.409). The median duration of OM was shorter in the probiotic group (10 vs. 12 days, p = 0.037). The incidence and duration of diarrhoea did not differ between the two groups. Moreover, the use of viable Bifidobacterium tablets had no influence on engraftment. CONCLUSIONS Our results suggested that viable Bifidobacterium tablets could effectively reduce the incidence of grades 1-2 OM and duration of OM during the transplant process without affecting the outcome of HSCT.
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Affiliation(s)
- Jingjing Guo
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
| | - Hongyong Zhang
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
| | - Xuan Lu
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
| | - Linghui Xia
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
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10
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Van Praet JT, Huysman A, De Knijf E, De Buyser S, Snauwaert S, Van Droogenbroeck J, Lodewyck T, Schauwvlieghe A, Selleslag D, Reynders M. Infectious diarrhea after allogeneic hematopoietic cell transplantation assessed by a multiplex polymerase chain reaction assay. Int J Infect Dis 2023; 127:17-22. [PMID: 36481487 DOI: 10.1016/j.ijid.2022.11.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/26/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To determine the incidence of infectious diarrhea after allogeneic hematopoietic cell transplantation (HCT) using a multiplex polymerase chain reaction assay and assess risk factors for developing infectious diarrhea. METHODS This was a single-center retrospective study of 140 consecutive allogeneic HCT recipients. Infectious diarrhea was assessed using a laboratory-developed multiplex polymerase chain reaction the first year after transplantation. RESULTS The incidence rate of infectious diarrhea episodes was 47 per 100 person-years, with the highest rate observed in the pre-engraftment phase. Most episodes were seen as nosocomial infections (38%) and most affected patients (82%) had only one episode of infectious diarrhea. The cumulative incidence of at least one episode of infectious diarrhea was 32% after 1 year. Nonrelapse mortality was higher in transplant recipients with at least one episode of infectious diarrhea (hazard ratio (HR) 2.02, 95% CI = 1.07-3.80). The most frequently observed pathogens were Clostridium difficile, adenovirus, Enteropathogenic Escherichia coli, and Campylobacter jejuni. Patients with acute lower gastrointestinal graft-vs-host disease stage 3 or 4 (HR 3.68, 95% CI = 1.57-8.63) conferred a higher risk for a first infectious diarrhea episode. CONCLUSION Infectious diarrhea after allogeneic HCT was seen in about one-third of the patients, mostly as nosocomial infection in the pre-engraftment phase.
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Affiliation(s)
- Jens T Van Praet
- Department of Nephrology and Infectious diseases, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium; Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
| | - Andreas Huysman
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Eline De Knijf
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Stefanie De Buyser
- Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Sylvia Snauwaert
- Department of Hematology, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
| | | | - Tom Lodewyck
- Department of Hematology, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
| | | | - Dominik Selleslag
- Department of Hematology, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
| | - Marijke Reynders
- Department of Medical Microbiology, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
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11
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Boulet E, Graux C, Sonet A, Depaus J, Vellemans H, André M, Fervaille C, Collinge E. Cryptosporidiosis, an Uncommon Complication after Allogeneic Stem-Cell Transplantation. Case Rep Oncol 2023; 16:591-596. [PMID: 37900815 PMCID: PMC10601728 DOI: 10.1159/000531571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 06/01/2023] [Indexed: 10/31/2023] Open
Abstract
Parasitic infections by Cryptosporidium species are rare but can be life-threatening disease after allogeneic stem-cell transplantation (allo-SCT). Here, we reported a case of cryptosporidiosis occurring after a reduced-intensity conditioning and allo-SCT in a 64-year-old farmer with diffuse large B-cell lymphoma. Around day 70 after allo-SCT, he presented with diarrhea attributed to graft-versus-host disease (GvHD) and was treated with immunosuppressive therapy. Due to the patient's worsening clinical condition, a biopsy review was performed, revealing evidence of cryptosporidiosis. Therefore, immunosuppressive therapy was progressively decreased, and antimicrobial therapy including paromomycin and azithromycin was initiated. Following an increase in diarrhea, a second-line treatment with nitazoxanide was administered, resulting in gradual improvement of symptoms. However, recurrence of cryptosporidiosis occurred despite treatment with paromomycin 6 months after transplant and after an episode of GvHD recurrence and colic cytomegalovirus reactivation. Antiparasitic treatment was stopped and azithromycin and rifaximine were started. Immunosuppressive therapy was also reduced. The good clinical evolution allowed for the cessation of all medications. In conclusion, Cryptosporidium infection can complicate allo-SCT and be mistaken for GvHD at the clinical and histologic levels. Early and accurate diagnosis is all the more important as the therapeutic approach for the two conditions is opposite: reduction versus intensification of immunosuppressive therapy. Nitazoxanide, paromomycin, and azithromycin are the first therapeutic options.
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Affiliation(s)
- Edwige Boulet
- Hematology Department, CHU UCL Namur, Namur, Belgium
| | - Carlos Graux
- Hematology Department, CHU UCL Namur, Namur, Belgium
| | - Anne Sonet
- Hematology Department, CHU UCL Namur, Namur, Belgium
| | - Julien Depaus
- Hematology Department, CHU UCL Namur, Namur, Belgium
| | | | - Marc André
- Hematology Department, CHU UCL Namur, Namur, Belgium
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12
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Kondapi DS, Ramani S, Estes MK, Atmar RL, Okhuysen PC. Norovirus in Cancer Patients: A Review. Open Forum Infect Dis 2021; 8:ofab126. [PMID: 34189156 PMCID: PMC8232388 DOI: 10.1093/ofid/ofab126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/10/2021] [Indexed: 12/15/2022] Open
Abstract
Norovirus (NoV) is the leading cause of viral-related diarrhea in cancer patients, in whom it can be chronic, contributing to decreased quality of life, interruption of cancer care, malnutrition, and altered mucosal barrier function. Immunosuppressed cancer patients shed NoV for longer periods of time than immunocompetent hosts, favoring quasispecies development and emergence of novel NoV variants. While nucleic acid amplification tests (NAATs) for NoV diagnosis have revolutionized our understanding of NoV burden of disease, not all NAATs provide information on viral load or infecting genotype. There is currently no effective antiviral or vaccine for chronic NoV infections. Screening for inhibitors of NoV replication in intestinal organoid culture models and creation of NoV-specific adoptive T cells are promising new strategies to develop treatments for chronic NoV in immunosuppressed patients. Herein we summarize data on the epidemiology, clinical manifestations, diagnostic challenges, and treatment of NoV infection in patients with cancer.
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Affiliation(s)
- Divya Samantha Kondapi
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Sasirekha Ramani
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Mary K Estes
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Robert L Atmar
- Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Pablo C Okhuysen
- Infection Control and Employee Health, Division of Internal Medicine, Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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13
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Non LR, Ince D. Infectious Gastroenteritis in Transplant Patients. Gastroenterol Clin North Am 2021; 50:415-430. [PMID: 34024449 DOI: 10.1016/j.gtc.2021.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Infectious gastroenteritis is common after transplantation and can lead to increased morbidity and mortality. A wide range of organisms can lead to gastroenteritis in this patient population. Clostridioides difficile, cytomegalovirus, and norovirus are the most common pathogens. Newer diagnostic methods, especially multiplex polymerase chain reaction, have increased the diagnostic yield of infectious etiologies. In this review, we describe the epidemiology and risk factors for common infectious pathogens leading to gastroenteritis.
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Affiliation(s)
- Lemuel R Non
- Department of Internal Medicine, University of Iowa, Carver College of Medicine, GH SW34, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Dilek Ince
- Department of Internal Medicine, University of Iowa, Carver College of Medicine, GH SE418, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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14
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Rogers WS, Westblade LF, Soave R, Jenkins SG, van Besien K, Singh HK, Walsh TJ, Small CB, Shore T, Crawford CV, Satlin MJ. Impact of a Multiplexed Polymerase Chain Reaction Panel on Identifying Diarrheal Pathogens in Hematopoietic Cell Transplant Recipients. Clin Infect Dis 2021; 71:1693-1700. [PMID: 31687767 DOI: 10.1093/cid/ciz1068] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 11/01/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Diarrhea is common and associated with substantial morbidity among hematopoietic cell transplant (HCT) recipients, but the etiology is often not identified. Multiplexed polymerase chain reaction (PCR) assays increase the detection of diarrheal pathogens, but the impact of this technology in this population has not been evaluated. METHODS Our center replaced stool cultures and other conventional microbiologic methods with the FilmArray Gastrointestinal Panel (GI PCR) in June 2016. We reviewed all adult patients who received an HCT from June 2014-May 2015 (pre-GI PCR, n = 163) and from June 2016-May 2017 (post-GI PCR, n = 182) and followed them for 1 year after transplantation. Clostridioides difficile infection was diagnosed by an independent PCR test in both cohorts. RESULTS The proportion of patients with ≥1 identified infectious diarrheal pathogen increased from 25% to 37% after implementation of GI PCR (P = .01). Eight patients (5%) in the pre-GI PCR cohort tested positive for a pathogen other than C. difficile versus 49 patients (27%) in the post-GI PCR cohort (P < .001). The most common non-C. difficile diarrheal pathogens in the post-GI PCR cohort were enteropathogenic Escherichia coli (n = 14, 8%), norovirus (n = 14, 8%), and Yersinia enterocolitica (n = 7, 4%). The percentage of diarrheal episodes with an identified infectious etiology increased from 14% to 23% (P = .001). Median total costs of stool testing per patient did not increase (pre: $473; post: $425; P = .25). CONCLUSIONS Infectious etiologies of diarrhea were identified in a higher proportion of HCT recipients after replacing conventional stool testing with a multiplexed PCR assay, without an increase in testing costs.
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Affiliation(s)
- Wesley S Rogers
- NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Lars F Westblade
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA.,Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA
| | - Rosemary Soave
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA.,Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York, New York, USA
| | - Stephen G Jenkins
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA.,Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA
| | - Koen van Besien
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Harjot K Singh
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA.,Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York, New York, USA
| | - Thomas J Walsh
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA.,Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York, New York, USA
| | - Catherine B Small
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA.,Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York, New York, USA
| | - Tsiporah Shore
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Carl V Crawford
- Division of Gastroenterology, Weill Cornell Medicine, New York, New York, USA
| | - Michael J Satlin
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA.,Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York, New York, USA
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15
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Berger T, Giladi O, Yahav D, Ben-Zvi H, Pasvolsky O, Shargian-Alon L, Wolach O, Rozovski U, Raanani P, Yeshurun M. Diarrheal Morbidity During Hematopoietic Cell Transplantation: The Diagnostic Yield of Stool Cultures. Infect Dis Ther 2021; 10:1023-1032. [PMID: 33661515 PMCID: PMC8116365 DOI: 10.1007/s40121-021-00415-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 02/10/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Diarrhea affects a significant proportion of patients undergoing hematopoietic cell transplantation (HCT). We explored the diagnostic yield of stool cultures for enteric pathogens among patients undergoing HCT. METHODS This is a single-center, retrospective study. Between 5/2007 and 4/2020, consecutive patients who underwent HCT were included if inpatient bacterial stool cultures were collected. Patient characteristics, results, and timing of stool cultures obtained during hospitalization were collected. RESULTS A total of 1072 individuals underwent autologous (n = 603) and allogeneic (n = 469) HCT. Overall, 947 stool culture samples were obtained from 561 (52%) patients with diarrheal illness during hospitalization for HCT. Most (99%) samples were obtained beyond 3 days of admission, mainly (77%) during neutropenia. Overall, only four (0.42%) (autologous, n = 3; allogeneic, n = 1) patients had a positive stool culture and in all cases Campylobacter spp. were the pathogens identified. The number of stool cultures needed-to-test to diagnose one case of bacterial infection was 237. The cost of diagnosing one case of bacterial diarrhea was US $8770. Patients with a positive stool culture did not have discerning characteristics. CONCLUSIONS In our experience, the yield of stool cultures for enteropathogens in patients undergoing HCT is extremely low and thus should be avoided in most cases.
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Affiliation(s)
- Tamar Berger
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Odil Giladi
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Haim Ben-Zvi
- Microbiology Laboratories, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Oren Pasvolsky
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liat Shargian-Alon
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Wolach
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Rozovski
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Yeshurun
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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16
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Abstract
PURPOSE OF REVIEW This review will focus on the epidemiology and cause of diarrheal illness in solid organ transplant and stem-cell transplant population recipients with a specific focus on the role of advanced multiplex technology in the diagnosis of diarrhea within this patient population. RECENT FINDINGS A wide range of infectious and noninfectious causes of diarrhea have been described in immunocompromised patients. The most common infections noted are Clostridioides difficile, norovirus, and cytomegalovirus, whereas immunosuppressive drugs and mucositis are the most common noninfectious causes of diarrhea. Historically, diagnostic evaluation has been limited to an array of single pathogen assays. Newer multiplex assays have become available that allow rapid, sensitive detection of a wide range of pathogens in a single assay. These assays have improved the number of patients with a diagnosed pathogen but may identify colonizing pathogens that are not pathogenic. Studies are needed to inform the discrimination and optimal use of these newer assays. SUMMARY Diarrhea is a common complication in immunocompromised patients and is associated with greater morbidity and rare mortality. New diagnostics facilitate detection of recognized pathogens and may allow for improved outcomes through the use of pathogen-targeted therapy.
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17
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Ford CD, Lopansri BK, Coombs J, Webb BJ, Asch J, Hoda D. Are Clostridioides difficile infections being overdiagnosed in hematopoietic stem cell transplant recipients? Transpl Infect Dis 2020; 22:e13279. [PMID: 32196881 DOI: 10.1111/tid.13279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/12/2020] [Accepted: 03/08/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Because both diarrhea due to other causes and gastrointestinal colonization with toxigenic Clostridioides difficile are common in HSCT, there is a possibility of false-positive diagnoses of C difficile infections (CDI). METHODS We estimated the probability of a patient being colonized by toxigenic C difficile by testing non-diarrheal surveillance stools from 223 HSCT recipients and the probability that a specimen submitted for C difficile testing was not CDI by determining the number of clinical tests that returned negative from this cohort. The number of expected false-positive CDI was estimated using these probabilities and compared with observed clinical test results. RESULTS The expected false-positive and the observed numbers of positive clinical results were similar. The 20 patients diagnosed with CDI were also similar to 142 patients with diarrhea and C difficile-negative stools in number of stools on day of testing, associated symptoms, and the recorded number of days to formed stools. C difficile colonization was most commonly detected during the first week and CDI during the second. Retrospective analysis of 837 patients showed that 18 stools were submitted for each diagnosis of CDI. Ribotyping of the surveillance samples showed 17 ribotypes. CONCLUSIONS Although several assumptions could impact the accuracy of our false-positive CDI estimates, it appears that many HSCT recipients diagnosed with CDI may actually represent colonized status and an alternative cause of diarrhea. Diagnostic stewardship, including limiting CDI diagnoses to patients with positive toxin and restricting stool submissions to patients with more severe symptoms, may decrease the number of false-positive diagnoses.
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Affiliation(s)
- Clyde D Ford
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT, USA
| | - Bert K Lopansri
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT, USA.,Department of Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA
| | - Jana Coombs
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Brandon J Webb
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT, USA.,Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Julie Asch
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT, USA
| | - Daanish Hoda
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT, USA
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18
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Czyzewski K, Dziedzic M, Salamonowicz M, Fraczkiewicz J, Zajac-Spychala O, Zaucha-Prazmo A, Gozdzik J, Galazka P, Bartoszewicz N, Demidowicz E, Styczynski J. Epidemiology, Outcome and Risk Factors Analysis of Viral Infections in Children and Adolescents Undergoing Hematopoietic Cell Transplantation: Antiviral Drugs Do Not Prevent Epstein-Barr Virus Reactivation. Infect Drug Resist 2019; 12:3893-3902. [PMID: 31908501 PMCID: PMC6925545 DOI: 10.2147/idr.s224291] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/05/2019] [Indexed: 12/28/2022] Open
Abstract
Objective The analysis of epidemiology, risk factors and outcome of viral infections in children and adolescents after hematopoietic cell transplantation (HCT). Methods In this multicenter nationwide study a total of 971 HCT procedures (741 allo-HCT; 230 auto-HCT) over a period of 6 years were analyzed. Results During this period 801 episodes of viral infections were diagnosed in 442 patients. The incidence of viral infections was 57.9% in allo-HCT and 4.8% in auto-HCT patients. The most frequent infections after allo-HCT were caused by cytomegalovirus (CMV), polyoma BK virus (BKV) and Epstein-Barr virus (EBV). The majority of infections occurred within the first 4 months after allo-HCT and over 80% required pharmacotherapy or symptomatic therapy. The median time of treatment of specific viral infection ranged from 7 (for EBV) to 24 (for CMV) days. The highest mortality was observed in case of CMV infection. The risk factors for viral infections were allo-HCT, acute leukemia, acute and chronic graft versus host disease (a/cGVHD), and matched unrelated donor (MUD)/mismatched unrelated donor (MMUD)-HCT. The risk factor for death from viral infection were CMV-IgG seropositivity in acute lymphoblastic leukemia recipient, and MUD/MMUD-HCT. The incidence of EBV infection requiring pre-emptive treatment with rituximab in allo-HCT children was 19.3%. In 30.8% cases of EBV infection, these episodes were preceded by other viral infection and treated with antivirals, which did not prevent development of EBV-DNA-emia with need of rituximab treatment in 81.5% cases. In 47.7% of these cases, GVHD was a factor enabling development of significant EBV-DNA-emia during antiviral therapy of other infection. Conclusion We have shown that antiviral drugs do not prevent EBV reactivation in allo-HCT pediatric patients.
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Affiliation(s)
- Krzysztof Czyzewski
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Magdalena Dziedzic
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Malgorzata Salamonowicz
- Department of Pediatric Transplantation, Oncology and Hematology, Medical University, Wroclaw, Poland
| | - Jowita Fraczkiewicz
- Department of Pediatric Transplantation, Oncology and Hematology, Medical University, Wroclaw, Poland
| | - Olga Zajac-Spychala
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - Agnieszka Zaucha-Prazmo
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, Medical University, Lublin, Poland
| | - Jolanta Gozdzik
- Stem Cell Transplant Center, University Children's Hospital, Department of Clinical Immunology and Transplantology, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Przemyslaw Galazka
- Department of General and Oncological Surgery for Children and Adolescents, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Natalia Bartoszewicz
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Ewa Demidowicz
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
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19
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Atilla E, Ataca Atilla P, Cengiz Seval G, Bektaş M, Demirer T. Current approach to early gastrointestinal and liver complications of hematopoietic stem cell transplantation. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 30:122-131. [PMID: 30459131 DOI: 10.5152/tjg.2018.18156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The gastrointestinal (GI) system is one of the most commonly affected sites during a hematopoietic stem cell transplantation (HSCT) due to toxicities of preparative regimens, the accompanying immunodeficiency, and organ damage caused by graft versus host disease. In this review, we focus on early GI and liver complications following autologous (auto-) and allogeneic (allo-) HSCT and clarify both the risk factors and therapeutic strategies. Early GI and liver complications associated with HSCT remain challenging issues. Despite the improvements in this field during the last decade, treatments for these complications still place a significant burden on both patients and the physicians treating these patients. GI and liver complications remain some of the causes of mortality associated with HSCT. For practicing hematologists, oncologists, and gastroenterologists in this field, the awareness and early diagnosis of the GI complications remain important factors to obtain optimal outcomes in this patient population.
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Affiliation(s)
- Erden Atilla
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Pınar Ataca Atilla
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Güldane Cengiz Seval
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Mehmet Bektaş
- Department of Gastroenterology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
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20
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The Effects of Fecal Donors with Different Feeding Patterns on Diarrhea in a Patient Undergoing Hematopoietic Stem Cell Transplantation. Case Rep Hematol 2019; 2019:4505238. [PMID: 31049232 PMCID: PMC6462343 DOI: 10.1155/2019/4505238] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/20/2018] [Accepted: 02/27/2019] [Indexed: 12/14/2022] Open
Abstract
Almost 90% of patients undergoing hematopoietic stem cell transplantation (HSCT) experience diarrheal episodes, which represent a severe, often life-threatening complication for these patients. Although fecal microbiota transplantation (FMT) represents an alternative treatment option for infection-related diarrhea, the application of FMT in HSCT patients is greatly restricted for safety reasons. Furthermore, the therapeutic outcomes of FMT as a diarrhea treatment are somewhat related to the choice of the FMT donor. Here, we comprehensively profiled the dynamic changes in the intestinal microbiota after FMT from two donors with different feeding patterns and the same severely diarrheal recipient undergoing HSCT via a 45-day clinical observation. Importantly, no adverse events attributed to FMT were observed. The stool volume and frequency of the patient were reduced when we used feces from donor #1 (mixed feeding), but these changes were not observed after FMT from donor #2 (exclusive breastfeeding). Interestingly, no obvious differences in overall diversity (Shannon) or richness (Chao1) between the two donors were observed. Additionally, Bifidobacterium accounted for 29.9% and 18.1% of OTUs in the stools of donors #1 and #2, respectively. Lactobacillus accounted for 16.3% and 2.9% of the stools of donors #1 and #2, respectively. Furthermore, through longitudinal monitoring of the patient, we identified 6 OTUs that were particularly sensitive to the different FMT complements. Together, we present a case report suggesting that the overall diversity of the intestinal microbiota may not be the only important element in the selection of an effective FMT donor.
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Cunha R. Diarrhea after autologous stem cell transplantation in low-middle income countries: is Clostridium difficile the most prevalent infectious etiology? Hematol Transfus Cell Ther 2018; 40:105-106. [PMID: 30057982 PMCID: PMC6001931 DOI: 10.1016/j.htct.2018.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Renato Cunha
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HC FMRP USP), Ribeirão Preto, SP, Brazil
- Experimental Transplantation and Immunology Branch, National Cancer Institute/National Institutes of Health, Bethesda, USA
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Castro MDD, Chebli JM, Costa LJ, Alves KRL, Atalla A, Neto AEH. Infectious diarrhea in autologous stem cell transplantation: high prevalence of coccidia in a South American center. Hematol Transfus Cell Ther 2018; 40:132-135. [PMID: 30057986 PMCID: PMC6001927 DOI: 10.1016/j.htct.2017.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 10/23/2017] [Indexed: 12/02/2022] Open
Abstract
Background Diarrhea is frequently seen in autologous stem cell transplantation. Although toxicity related to conditioning is the most common cause, infectious pathogens can play a distinctive role particularly in certain regions and environments. Methods The role of enteropathogens was investigated in 47 patients submitted to autologous stem cell transplantation at a Brazilian center between May 2011 and May 2013. All patients who presented with diarrhea consented to stool sample analysis to identify the etiological agents including coccidia, Strongyloides sp., Clostridium difficile and other pathogenic bacteria. Results Thirty-nine patients (83%) had diarrhea, among whom seven (17.5%) presented with coccidia, three (7.5%) with Candida sp., one (2.5%) with C. difficile, and one (2.5%) with Giardia lamblia. There was a tendency toward a higher incidence of diarrhea in older patients (p-value = 0.09) and those who received conditioning with lomustine, etoposide, cytarabine, and melphalan (p-value = 0.083). Furthermore, the number of days of neutropenia was higher in patients with diarrhea (p-value = 0.06). Conclusions The high frequency of diarrhea caused by coccidia shows the importance of investigating and correctly identifying etiological agents and highlights the possible varieties of intestinal infections in patients who undergo autologous stem cell transplantation.
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Affiliation(s)
- Marcelo Dias de Castro
- Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, MG, Brazil
- Faculdade de Medicina de Barbacena (FAME), Barbacena, MG, Brazil
| | | | | | - Katia Regina Lopes Alves
- Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, MG, Brazil
- Corresponding author at: Universidade Federal de Juiz de For a (UFJF), Rua Catulo Breviglieri, s/n, Santa Catarina, CEP: 36036110, Juiz de Fora, MG, Brazil.
| | - Angelo Atalla
- Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, MG, Brazil
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Robin C, Héquette-Ruz R, Guery B, Boyle E, Herbaux C, Galperine T. Treating Clostridium difficile infection in patients presenting with hematological malignancies: Are current guidelines applicable? Med Mal Infect 2017; 47:532-539. [PMID: 28823390 DOI: 10.1016/j.medmal.2017.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/15/2016] [Accepted: 07/10/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Adults with hematological malignancies are at high-risk of Clostridium difficile infection (CDI), but no guidelines for CDI treatment are available in this population. Our primary objective was to evaluate the clinical outcomes in CDI patients with hematological malignancies. Our secondary objectives were to describe CDI severity using the main clinical guidelines and to evaluate the compliance of treatment choice with published guidelines. PATIENTS AND METHODS Single-center, retrospective, observational case series including every consecutive adult patient with a confirmed diagnosis of CDI admitted in the hematology unit of our teaching hospital. Each CDI episode was classified as moderate, severe, or complicated according to the main clinical guidelines (IDSA 2010, AJG 2013, ESCMID 2014). RESULTS Twenty-three episodes of CDI in 19 patients admitted to the hematology unit occurred between June 2012 and October 2013. Clinical cure was achieved for 20 episodes (87%). Ten weeks after diagnosis, global cure was reached for 14 episodes (61%) whereas recurrence occurred in two episodes (10%). The mortality rate reached 37% (7/19) but the attributable mortality rate was 5% (1/19). ESCMID criteria more frequently classified patients in the severe category compared with the two other classifications. Prescription compliance with clinical guidelines was observed in 61% of episodes with IDSA criteria, 43% with AJG, and 9% with ESCMID. CONCLUSIONS IDSA and AJG assessment may underestimate the potential risk of unfavorable clinical outcome. Further prospective studies on a larger cohort are needed to develop adequate treatment guidelines for CDI in hematology settings.
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Affiliation(s)
- C Robin
- Department of Hematology, Henri-Mondor Teaching Hospital, University Paris-Est Créteil (UPEC), Assistance publique-Hôpitaux de Paris (AP-HP), 94000 Créteil, France; University Paris-Est Créteil (UPEC), 94000 Créteil, France
| | - R Héquette-Ruz
- Department of Infectious Diseases, CHU de Lille, 59000 Lille, France
| | - B Guery
- Infectious Diseases Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - E Boyle
- Department of Hematology, CHU de Lille, 59000 Lille, France
| | - C Herbaux
- Department of Hematology, CHU de Lille, 59000 Lille, France
| | - T Galperine
- Infectious Diseases Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland.
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Fabiani S, Fortunato S, Petrini M, Bruschi F. Allogeneic hematopoietic stem cell transplant recipients and parasitic diseases: A review of the literature of clinical cases and perspectives to screen and follow-up active and latent chronic infections. Transpl Infect Dis 2017; 19. [PMID: 28128496 DOI: 10.1111/tid.12669] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 10/20/2016] [Accepted: 10/29/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplant (HSCT) recipients are at substantial risk for a variety of infections depending upon numerous factors, such as degree of immunosuppression, host factors, and period after transplantation. Bacterial, fungal, viral, as well as parasitic infections can occur with high morbidity and mortality. OBJECTIVES The aim of this study was to evaluate the magnitude of the occurrence of parasitic infections in allogeneic HSCT recipients. Modalities of transmission, methods of diagnosis, treatment, donor and recipient pre-transplant screening and prevention measures of the most serious parasitic infections have also been discussed. MATERIALS AND METHODS We systematically reviewed literature records on post-transplant (allogeneic HSCT) parasitic infections, identified through PubMed database searching, using no language or time restrictions. Search was concluded on December 31, 2015. In the present review, we only discussed post-transplant parasitic infections in allogeneic HSCT. Only exclusion criteria were absence of sufficient information on the transmission of parasitic infection to the recipient. Autologous HSCT recipients have not been included because of the absence of a proper allogeneic transplantation even in presence of blood or blood product transfusions. The methods and findings of the present review have been reported based on the preferred reporting items for systematic reviews and meta-analysis checklist (PRISMA). RESULTS Regarding allogeneic HSCT recipients, from data published in the literature the real burden of parasitic infections cannot be really estimated. Nevertheless, a positive trend on publication number exists, probably because of more than one reason: (i) the increasing number of patients transplanted and then treated with immunosuppressive agents, (ii) the "population shift" resulting from immigration and travels to endemic areas, and (iii) the increasing of attention for diagnosis/notification/publication of cases. CONCLUSIONS Considering parasitic infections as emerging and potentially serious in their evolution, additional strategies for the prevention, careful screening and follow-up, with a high level of suspicion, identification, and preemptive therapy are necessary in transplant recipients. PERSPECTIVES The Authors' viewpoint in the perspective to screen and follow-up active and latent chronic parasitosis in stem cells donors and recipients: a proposal for a flow chart.
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Affiliation(s)
- Silvia Fabiani
- School of Infectious Diseases, Università di Pisa, Pisa, Italy
| | | | - Mario Petrini
- Department of Experimental and Clinical Medicine, Università di Pisa, Pisa, Italy.,Unit of Hematology, AOU Pisana, Pisa, Italy
| | - Fabrizio Bruschi
- School of Infectious Diseases, Università di Pisa, Pisa, Italy.,Department of Translational Research, N.T.M.S., Università di Pisa, Pisa, Italy
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Scardina TL, Kang Martinez E, Balasubramanian N, Fox-Geiman M, Smith SE, Parada JP. Evaluation of Risk Factors for Clostridium difficile Infection in Hematopoietic Stem Cell Transplant Recipients. Pharmacotherapy 2017; 37:420-428. [PMID: 28226419 DOI: 10.1002/phar.1914] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVES The primary objective was to determine the impact of hematologic malignancies and/or conditioning regimens on the risk of developing Clostridium difficile infection (CDI) in patients undergoing hematopoietic stem cell transplantation (HSCT). Secondary objectives were to determine if traditional CDI risk factors applied to patients undergoing HSCT and to determine the presence of CDI markers of severity of illness among this patient population. DESIGN Single-center retrospective case-control study. SETTING Quaternary care academic medical center. PATIENTS A total of 105 patients who underwent HSCT between December 2009 and December 2014; of these patients, 35 developed an initial episode of CDI (HSCT/CDI group [cases]), and 70 did not (controls). Controls were matched in a 2:1 ratio to cases based on age (± 10 yrs) and date of HSCT (± 6 mo). MEASUREMENTS AND MAIN RESULTS Baseline characteristics of the two groups were well balanced regarding age, sex, race, ethnicity, and type of HSCT. No significant differences in conditioning regimen, hematologic malignancy, total body irradiation received for HSCT, use of antibiotics within 60 days of HSCT, or use of prophylactic antibiotics after HSCT were noted between the two groups. Patients in the control group were 10.57 (95% confidence interval 1.24-492.75) more likely to have received corticosteroids prior to HSCT than patients in the HSCT/CDI group (p=0.01). Use of proton pump inhibitors at the time of HSCT was greater among the control group than among patients in the HSCT/CDI group (97% vs 86%, p=0.048). No significant difference in mortality was noted between the groups at 3, 6, and 12 months after HSCT. Metronidazole was frequently prescribed for patients in the HSCT/CDI group (34 patients [97%]). Severe CDI was not common among patients within the HSCT/CDI group (13 patients [37%]); vancomycin was infrequently prescribed for these patients ([31%] 4/13 patients). CONCLUSION Hematologic malignancies and a conditioning regimen administered for HSCT were not significant risk factors for the development of CDI after HSCT. Use of corticosteroids prior to HSCT and use of proton pump inhibitors at the time of HSCT were associated with a significantly decreased risk of CDI.
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Affiliation(s)
- Tonya L Scardina
- Department of Pharmacy, Loyola University Medical Center, Maywood, Illinois
| | | | | | - Mary Fox-Geiman
- Department of Pharmacy, Loyola University Medical Center, Maywood, Illinois
| | - Scott E Smith
- Division of Hematology/Oncology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Jorge P Parada
- Division of Infectious Diseases, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
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Risk for Clostridium difficile Infection After Allogeneic Hematopoietic Cell Transplant Remains Elevated in the Postengraftment Period. Transplant Direct 2017; 3:e145. [PMID: 28405601 PMCID: PMC5381738 DOI: 10.1097/txd.0000000000000662] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 01/31/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a frequent cause of diarrhea among allogeneic hematopoietic cell transplant (HCT) recipients. It is unknown whether risk factors for CDI vary by time posttransplant. METHODS We performed a 3-year prospective cohort study of CDI in allogeneic HCT recipients. Participants were enrolled during their transplant hospitalizations. Clinical assessments were performed weekly during hospitalizations and for 12 weeks posttransplant, and monthly for 30 months thereafter. Data were collected through patient interviews and chart review, and included CDI diagnosis, demographics, transplant characteristics, medications, infections, and outcomes. CDI cases were included if they occurred within 1 year of HCT and were stratified by time from transplant. Multivariable logistic regression was used to determine risk factors for CDI. RESULTS One hundred eighty-seven allogeneic HCT recipients were enrolled, including 63 (34%) patients who developed CDI. 38 (60%) CDI cases occurred during the preengraftment period (days 0-30 post-HCT) and 25 (40%) postengraftment (day >30). Lack of any preexisting comorbid disease was significantly associated with lower risk of CDI preengraftment (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-0.9). Relapsed underlying disease (OR, 6.7; 95% CI, 1.3-33.1), receipt of any high-risk antimicrobials (OR, 11.8; 95% CI, 2.9-47.8), and graft-versus-host disease (OR, 7.8; 95% CI, 2.0-30.2) were significant independent risk factors for CDI postengraftment. CONCLUSIONS A large portion of CDI cases occurred during the postengraftment period in allogeneic HCT recipients, suggesting that surveillance for CDI should continue beyond the transplant hospitalization and preengraftment period. Patients with continued high underlying severity of illness were at increased risk of CDI postengraftment.
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27
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Marr KA. Infections in Hematopoietic Stem Cell Transplant Recipients. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00080-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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28
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Weidner AS, Panarelli NC, Rennert H, Jessurun J, Yantiss RK. Immunohistochemistry Improves the Detection of Adenovirus in Gastrointestinal Biopsy Specimens From Hematopoietic Stem Cell Transplant Recipients. Am J Clin Pathol 2016; 146:627-631. [PMID: 27744342 DOI: 10.1093/ajcp/aqw179] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Gastrointestinal infections by cytomegalovirus (CMV) and adenovirus may complicate hematopoietic stem cell transplantation (HSCT). Although CMV and adenovirus produce recognizable cytopathic changes, these changes may be subtle or focal. The value of viral immunohistochemistry in detecting infection in HSCT recipients when cytopathic changes are not identified has not been demonstrated. METHODS H&E-stained sections from gastrointestinal biopsy specimens were reviewed by three pathologists. Cases were classified as negative, suspicious, or positive for CMV and/or adenovirus infection based on the presence or absence of viral inclusions. Viral immunohistochemistry was performed, and the results were compared with the interpretations of H&E-stained sections. RESULTS Four of 104 cases contained viral inclusions confirmed by immunohistochemistry: two were infected with CMV, and two were positive for adenovirus. All three reviewers correctly classified both immunopositive CMV cases on H&E evaluation. However, all reviewers missed the diagnosis of adenovirus on H&E assessment in one case. CONCLUSIONS In HSCT recipients, cytopathic changes of adenovirus may be easily missed in H&E-stained sections of gastrointestinal biopsy specimens. Thus, the routine use of adenovirus immunohistochemistry in all cases is recommended. Both cases of CMV infection were apparent on H&E evaluation, so the judicious use of immunohistochemical stains for CMV in selected cases may be considered.
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Affiliation(s)
- Anna-Sophie Weidner
- From the Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
| | | | - Hanna Rennert
- From the Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
| | - Jose Jessurun
- From the Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
| | - Rhonda K Yantiss
- From the Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
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29
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Renteria AS, Levine JE, Ferrara JLM. Therapeutic targets and emerging treatment options in gastrointestinal acute graft-versus-host disease. Expert Opin Orphan Drugs 2016; 4:469-484. [PMID: 30057862 DOI: 10.1517/21678707.2016.1166949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction Graft-versus-host disease (GVHD) continues to be the major lethal complication of allogeneic hematopoietic stem cell transplantation (HCT) but the standard of care, high dose steroids, has not changed in 40 years. Approximately 50% of GVHD patients will develop steroid refractory disease, typically involving the gastrointestinal (GI) tract, which has a very poor prognosis. Newly developed GVHD biomarker-based risk scores provide the first opportunity to treat patients at the onset of symptoms according to risk of steroid failure. Furthermore, improvements in our understanding of the pathobiology of GVHD, its different signaling pathways, involved cytokines, and the role of post-translational and epigenetic modifications, has identified new therapeutic targets for clinical trials. Areas covered This manuscript summarizes the pathophysiology, diagnosis, staging, current and new targeted therapies for GVHD, with an emphasis on GI GVHD. A literature search on PubMed was undertaken and the most relevant references included. Expert Opinion The standard treatment for GVHD, high dose steroids, offers less than optimal outcomes as well as significant toxicities. Better treatments, especially for GI GVHD, are needed to reduce non-relapse mortality after allogeneic HCT. The identification of high risk patients through a biomarker-defined scoring system offers a personalized approach to a disease that still requires significant research attention.
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Affiliation(s)
- Anne S Renteria
- Blood and Marrow Transplantation Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John E Levine
- Blood and Marrow Transplantation Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James L M Ferrara
- Hematologic Malignancies Translational Research Center, Blood and Marrow Transplantation Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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30
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Hamdeh S, Abdelrahman AAM, Elsallabi O, Pathak R, Giri S, Mosalpuria K, Bhatt VR. Clinical approach to diarrheal disorders in allogeneic hematopoietic stem cell transplant recipients. World J Hematol 2016; 5:23-30. [DOI: 10.5315/wjh.v5.i1.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/03/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
Diarrhea is a common complication of allogeneic hematopoietic stem cell transplant (HSCT), with an average incidence of approximately 40%-50%. A wide variety of etiologies can contribute to diarrhea in HSCT patients, including medication-induced mucosal inflammation, infections, graft-vs-host disease and cord colitis syndrome in umbilical cord blood transplant. Clinical manifestations can vary from isolated diarrheal episodes, to other organ involvement including pneumonia or myocarditis, and rarely multiorgan failure. The approach for diagnosis of diarrheal disorders in HSCT patients depends on the most likely cause. Given the risk of life-threatening conditions, the development of clinically significant diarrhea requires prompt evaluation, supportive care and specific therapy, as indicated. Serious metabolic and nutritional disturbances can happen in HSCT patients, and may even lead to mortality. In this review, we aim to provide a practical approach to diagnosis and management of diarrhea in the post-transplant period.
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Trubiano JA, Worth LJ, Thursky KA, Slavin MA. The prevention and management of infections due to multidrug resistant organisms in haematology patients. Br J Clin Pharmacol 2015; 79:195-207. [PMID: 24341410 DOI: 10.1111/bcp.12310] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 12/09/2013] [Indexed: 12/15/2022] Open
Abstract
Infections due to resistant and multidrug resistant (MDR) organisms in haematology patients and haematopoietic stem cell transplant recipients are an increasingly complex problem of global concern. We outline the burden of illness and epidemiology of resistant organisms such as gram-negative pathogens, vancomycin-resistant Enterococcus faecium (VRE), and Clostridium difficile in haematology cohorts. Intervention strategies aimed at reducing the impact of these organisms are reviewed: infection prevention programmes, screening and fluoroquinolone prophylaxis. The role of newer therapies (e.g. linezolid, daptomycin and tigecycline) for treatment of resistant and MDR organisms in haematology populations is evaluated, in addition to the mobilization of older agents (e.g. colistin, pristinamycin and fosfomycin) and the potential benefit of combination regimens.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC
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32
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Pilcante J, Rojas P, Ernst D, Sarmiento M, Ocqueteau M, Bertin P, García M, Rodriguez M, Jara V, Ajenjo M, Ramirez P. Clostridium difficile infection in Chilean patients submitted to hematopoietic stem cell transplantation. Rev Bras Hematol Hemoter 2015; 37:388-94. [PMID: 26670401 PMCID: PMC4678790 DOI: 10.1016/j.bjhh.2015.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/22/2015] [Accepted: 07/27/2015] [Indexed: 12/21/2022] Open
Abstract
Introduction Patients submitted to hematopoietic stem cell transplantation have an increased risk of Clostridium difficile infection and multiple risk factors have been identified. Published reports have indicated an incidence from 9% to 30% of transplant patients however to date there is no information about infection in these patients in Chile. Methods A retrospective analysis was performed of patients who developed C. difficile infection after hematopoietic stem cell transplantations from 2000 to 2013. Statistical analysis used the Statistical Package for the Social Sciences software. Results Two hundred and fifty patients were studied (mean age: 39 years; range: 17–69), with 147 (59%) receiving allogeneic transplants and 103 (41%) receiving autologous transplants. One hundred and ninety-two (77%) patients had diarrhea, with 25 (10%) cases of C. difficile infection being confirmed. Twenty infected patients had undergone allogeneic transplants, of which ten had acute lymphoblastic leukemia, three had acute myeloid leukemia and seven had other diseases (myelodysplastic syndrome, chronic myeloid leukemia, severe aplastic anemia). In the autologous transplant group, five patients had C. difficile infection; two had multiple myeloma, one had amyloidosis, one had acute myeloid leukemia and one had germinal carcinoma. The overall incidence of C. difficile infection was 4% within the first week, 6.4% in the first month and 10% in one year, with no difference in overall survival between infected and non-infected groups (72.0% vs. 67.6%, respectively; p-value = 0.56). Patients infected after allogeneic transplants had a slower time to neutrophil engraftment compared to non-infected patients (17.5 vs. 14.9 days, respectively; p-value = 0.008). In the autologous transplant group there was no significant difference in the neutrophil engraftment time between infected and non-infected patients (12.5 days vs. 11.8 days, respectively; p-value = 0.71). In the allogeneic transplant group, the median time to acute graft-versus-host disease was similar between the two groups (p-value = 0.08), as was the incidence of grades 1–4 acute graft-versus-host disease (40% vs. 48%; p-value >0.05). Conclusion The incidence of C. difficile infection after hematopoietic stem cell transplantation was low, with a significant number of cases occurring shortly after transplantation. Allogeneic transplants had a three-time higher risk of infection compared to autologous transplants, but this was not associated with increased mortality, decreased overall survival or higher risk of acute graft-versus-host disease.
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Affiliation(s)
| | | | - Daniel Ernst
- Pontificia Universidad Católica, Santiago, Chile
| | | | | | - Pablo Bertin
- Pontificia Universidad Católica, Santiago, Chile
| | - Maria García
- Pontificia Universidad Católica, Santiago, Chile
| | | | | | - Maria Ajenjo
- Pontificia Universidad Católica, Santiago, Chile
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Ye X, Van JN, Munoz FM, Revell PA, Kozinetz CA, Krance RA, Atmar RL, Estes MK, Koo HL. Noroviruses as a Cause of Diarrhea in Immunocompromised Pediatric Hematopoietic Stem Cell and Solid Organ Transplant Recipients. Am J Transplant 2015; 15:1874-81. [PMID: 25788003 PMCID: PMC4780324 DOI: 10.1111/ajt.13227] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 01/05/2015] [Accepted: 01/14/2015] [Indexed: 01/25/2023]
Abstract
Case reports describe significant norovirus gastroenteritis morbidity in immunocompromised patients. We evaluated norovirus pathogenesis in prospectively enrolled solid organ (SOT) and hematopoietic stem cell transplant (HSCT) patients with diarrhea who presented to Texas Children's Hospital and submitted stool for enteric testing. Noroviruses were detected by real-time reverse transcription polymerase chain reaction. Clinical outcomes of norovirus diarrhea and non-norovirus diarrhea patients, matched by transplanted organ type, were compared. Norovirus infection was identified in 25 (22%) of 116 patients, more frequently than other enteropathogens. Fifty percent of norovirus patients experienced diarrhea lasting ≥14 days, with median duration of 12.5 days (range 1-324 days); 29% developed diarrhea recurrence. Fifty-five percent of norovirus patients were hospitalized for diarrhea, with 27% requiring intensive care unit (ICU) admission. One HSCT recipient developed pneumatosis intestinalis. Three HSCT patients expired ≤6 months of norovirus diarrhea onset. Compared to non-norovirus diarrhea patients, norovirus patients experienced significantly more frequent ICU admission (27% vs. 0%, p = 0.02), greater serum creatinine rise (median 0.3 vs. 0.2 mg/dL, p = 0.01), and more weight loss (median 1.6 vs. 0.6 kg, p < 0.01). Noroviruses are an important cause of diarrhea in pediatric transplant patients and are associated with significant clinical complications.
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Affiliation(s)
- Xunyan Ye
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - John N. Van
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Flor M. Munoz
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, TX,Texas Children’s Hospital, Houston, TX
| | - Paula A. Revell
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Department of Pathology, Baylor College of Medicine, Houston, TX,Texas Children’s Hospital, Houston, TX
| | - Claudia A Kozinetz
- Department of Biostatistics and Epidemiology, East Tennessee State University, Johnson City, TN
| | - Robert A. Krance
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Texas Children’s Hospital, Houston, TX
| | - Robert L. Atmar
- Department of Medicine, Baylor College of Medicine, Houston, TX,Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, TX
| | - Mary K. Estes
- Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, TX
| | - Hoonmo L. Koo
- Department of Medicine, Baylor College of Medicine, Houston, TX,Texas Children’s Hospital, Houston, TX
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Yin Y, Metselaar HJ, Sprengers D, Peppelenbosch MP, Pan Q. Rotavirus in organ transplantation: drug-virus-host interactions. Am J Transplant 2015; 15:585-93. [PMID: 25693470 DOI: 10.1111/ajt.13135] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/21/2014] [Accepted: 12/01/2014] [Indexed: 01/25/2023]
Abstract
Although rotavirus is usually recognized as the most common etiology of diarrhea in young children, it can in fact cause severe diseases in organ transplantation recipients irrespective of pediatric or adult patients. This comprehensive literature analysis revealed 200 cases of rotavirus infection with 8 related deaths in the setting of organ transplantation been recorded. Based on published cohort studies, an average incidence of 3% (187 infections out of 6176 organ recipients) was estimated. Rotavirus infection often causes severe gastroenteritis complications and occasionally contributes to acute cellular rejection in these patients. Immunosuppressive agents, universally used after organ transplantation to prevent organ rejection, conceivably play an important role in such a severe pathogenesis. Interestingly, rotavirus can in turn affect the absorption and metabolism of particular immunosuppressive medications via several distinct mechanisms. Even though rotaviral enteritis is self-limiting in general, infected transplantation patients are usually treated with intensive care, rehydration and replacement of nutrition, as well as applying preventive strategies. This article aims to properly assess the clinical impact of rotavirus infection in the setting of organ transplantation and to disseminate the interactions among the virus, host and immunosuppressive medications.
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Affiliation(s)
- Y Yin
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
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35
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Dubberke ER, Sadhu J, Gatti R, Reske KA, DiPersio JF, Devine SM, Fraser VJ. Severity of Clostridium difficile–Associated Disease (CDAD) in Allogeneic Stem Cell Transplant Recipients: Evaluation of a CDAD Severity Grading System. Infect Control Hosp Epidemiol 2015; 28:208-11. [PMID: 17265405 DOI: 10.1086/511792] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2006] [Accepted: 05/03/2006] [Indexed: 11/03/2022]
Abstract
The purpose of this study was to develop and test a Clostridium difficile-associated disease (CDAD) grading system based on presenting symptoms in allogeneic stem cell transplant recipients. Patients with severe CDAD had significantly shorter median survival times and more adverse outcomes than patients with mild or moderate CDAD.
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Affiliation(s)
- Erik R Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO 63110, USA.
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36
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Young JAH, Weisdorf DJ. Infections in Recipients of Hematopoietic Stem Cell Transplants. MANDELL, DOUGLAS, AND BENNETT'S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES 2015. [PMCID: PMC7152282 DOI: 10.1016/b978-1-4557-4801-3.00312-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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37
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Nitazoxanide for Cryptosporidiosis After Hematopoietic Stem Cell Transplantation. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2014. [DOI: 10.1097/ipc.0000000000000166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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38
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Abstract
Acute gastroenteritis caused by noroviruses often has a duration of 2-3 days and is characteristically self-limiting. In contrast, chronic infection caused by noroviruses in immunocompromised individuals can last from weeks to years, making clinical management difficult. The mechanisms by which noroviruses establish persistent infection, and the role of immunocompromised hosts as a reservoir for noroviruses in the general human population, are not known. However, study of this patient cohort may lead to new insights into norovirus biology and approaches to treatment.
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Affiliation(s)
- K Y Green
- Caliciviruses Section, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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39
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Neemann K, Minhas V, Loberiza FR, Freifield A. Transplant related outcomes in patients with hematopoietic stem cell transplant withClostridium difficileassociated diarrhea. Leuk Lymphoma 2014; 56:260-2. [DOI: 10.3109/10428194.2014.917637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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40
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Incidence and outcomes of Clostridium difficile-associated disease in hematopoietic cell transplant recipients. Int J Hematol 2014; 99:758-65. [DOI: 10.1007/s12185-014-1577-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/23/2014] [Accepted: 03/25/2014] [Indexed: 12/13/2022]
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41
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Owen L, Jones G, Despott EJ, Murray C, Atkinson C, Beal I, Webster DP. Fatal enteritis in a renal transplant patient with post-transplant thrombotic microangiopathy undergoing plasma exchange therapy. J Clin Virol 2014; 59:213-7. [PMID: 24495848 DOI: 10.1016/j.jcv.2014.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 01/04/2014] [Accepted: 01/06/2014] [Indexed: 11/20/2022]
Affiliation(s)
- Leah Owen
- Watford General Hospital, Vicarage Road, Watford, Hertfordshire, WD18 0HB, United Kingdom.
| | - Gareth Jones
- Royal Free Hospital, Pond Street, London NW3 2QG, United Kingdom.
| | - Edward J Despott
- Royal Free Unit for Endoscopy & Centre for Gastroenterology, UCL Institute for Liver & Digestive Health, 8th Floor South Offices, Royal Free Hospital and University College London, Pond Street, London NW3 2QG, United Kingdom.
| | - Claire Murray
- Department of Cellular Pathology, Royal Free Hospital NHS Trust, Pond Street, London, NW3 2QG, United Kingdom.
| | - Claire Atkinson
- Department of Virology, Royal Free Hospital and University College London, Pond Street, London NW3 2QG, United Kingdom.
| | - Isobel Beal
- Royal Free Hospital, Pond Street, London NW3 2QG, United Kingdom.
| | - Daniel P Webster
- Department of Virology, Royal Free Hospital and University College London, Pond Street, London NW3 2QG, United Kingdom.
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42
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Lin R, Liu Q. Diagnosis and treatment of viral diseases in recipients of allogeneic hematopoietic stem cell transplantation. J Hematol Oncol 2013; 6:94. [PMID: 24341630 PMCID: PMC3878524 DOI: 10.1186/1756-8722-6-94] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 11/30/2013] [Indexed: 11/11/2022] Open
Abstract
Viral infections are important causes of morbidity and mortality after allogeneic stem cell hematopoietic transplantation (allo-HSCT). Although most viral infections present with asymptomatic or subclinical manifestations, viruses may result in fatal complications in severe immunocompromised recipients. Reactivation of latent viruses, such as herpesviruses, is frequent during the immunosuppression that occurs with allo-HSCT. Viruses acquired from community, such as the respiratory and gastrointestinal viruses, are also important pathogens of post-transplant viral diseases. Currently, molecular diagnostic methods have replaced or supplemented traditional methods, such as viral culture and antigen detection, in diagnosis of viral infections. The utilization of polymerase chain reaction facilitates the early diagnosis. In view of lacking efficacious agents for treatment of viral diseases, prevention of viral infections is extremely valuable. Application of prophylactic strategies including preemptive therapy reduces viral infections and diseases. Adoptive cellular therapy for restoring virus-specific immunity is a promising method in the treatment of viral diseases.
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Affiliation(s)
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou Dadao North Street, 1838, Guangzhou China.
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43
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Bhatt AS, Freeman SS, Herrera AF, Pedamallu CS, Gevers D, Duke F, Jung J, Michaud M, Walker BJ, Young S, Earl AM, Kostic AD, Ojesina AI, Hasserjian R, Ballen KK, Chen YB, Hobbs G, Antin JH, Soiffer RJ, Baden LR, Garrett WS, Hornick JL, Marty FM, Meyerson M. Sequence-based discovery of Bradyrhizobium enterica in cord colitis syndrome. N Engl J Med 2013; 369:517-28. [PMID: 23924002 PMCID: PMC3889161 DOI: 10.1056/nejmoa1211115] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Immunosuppression is associated with a variety of idiopathic clinical syndromes that may have infectious causes. It has been hypothesized that the cord colitis syndrome, a complication of umbilical-cord hematopoietic stem-cell transplantation, is infectious in origin. METHODS We performed shotgun DNA sequencing on four archived, paraffin-embedded endoscopic colon-biopsy specimens obtained from two patients with cord colitis. Computational subtraction of human and known microbial sequences and assembly of residual sequences into a bacterial draft genome were performed. We used polymerase-chain-reaction (PCR) assays and fluorescence in situ hybridization to determine whether the corresponding bacterium was present in additional patients and controls. RESULTS DNA sequencing of the biopsy specimens revealed more than 2.5 million sequencing reads that did not match known organisms. These sequences were computationally assembled into a 7.65-Mb draft genome showing a high degree of homology with genomes of bacteria in the bradyrhizobium genus. The corresponding newly discovered bacterium was provisionally named Bradyrhizobium enterica. PCR identified B. enterica nucleotide sequences in biopsy specimens from all three additional patients with cord colitis whose samples were tested, whereas B. enterica sequences were absent in samples obtained from healthy controls and patients with colon cancer or graft-versus-host disease. CONCLUSIONS We assembled a novel bacterial draft genome from the direct sequencing of tissue specimens from patients with cord colitis. Association of these sequences with cord colitis suggests that B. enterica may be an opportunistic human pathogen. (Funded by the National Cancer Institute and others.)
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Affiliation(s)
- Ami S Bhatt
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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Şıvgın S, Eser B, Kaynar L, Kurnaz F, Şıvgın H, Yazar S, Çetin M, Ünal A. Encephalitozoon intestinalis: A Rare Cause of Diarrhea in an Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) Recipient Complicated by Albendazole-Related Hepatotoxicity. Turk J Haematol 2013; 30:204-8. [PMID: 24385787 PMCID: PMC3878461 DOI: 10.4274/tjh.90692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 01/02/2012] [Indexed: 02/08/2023] Open
Abstract
UNLABELLED A 50-year-old male patient previously diagnosed with acute myelomonocytic (M4) leukemia in July 2009 underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT). During the pre-transplant period complete blood count (CBC), liver and renal function tests, coagulation tests, and other parameters were normal. On the first day of transplantation teicoplanin (400 mg d-1 for the first 3 d, and then 400 mg d-1) and caspofungin (first dose was 1×70 mg d-1, followed by 1×50 mg d-1) were started intravenously due to white plaques and oropharyngeal candidiasis in the patient's mouth and perianal erythema. On the 14th d of transplantation watery diarrhea occurred, along with abdominal discomfort, nausea, and fatigue. Stool examination was negative for findings of bleeding. Investigation of Microsporidia confirmed a rare pathogen Encephalitozoon intestinalis in the patient's stool sample via species-specific immunofluorescence antibody (IFA) assay and albendazole treatment was started at a dose of 2×400 mg d-1. On the 5th d of albendazole treatment (d 18 of treatment) liver function test (LFT) results began to deteriorate. As LFT results continued to deteriorate, albendazole was withdrawn on the 7th d of treatment. Biopsy was performed on the 22nd d of transplantation and histopathological analysis confirmed the diagnosis of toxic hepatitis. LFT results began to decrease after withdrawal of albendazole treatment. On the 13th d of albendazole treatment all LFT values returned to normal. The presented allo-HSCT case had a rare pathogenic agent (E. intestinalis) that caused diarrhea, as well as hepatotoxicity due to albendazole treatment. This is the first reported case of E. intestinalis diagnosed via IFA in Turkey. CONFLICT OF INTEREST None declared.
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Affiliation(s)
- Serdar Şıvgın
- Erciyes University, School of Medicine, Department of Hematology, Dedeman Stem Cell Transplantation Hospital, Kayseri, Turkey
- * Address for Correspondence: Erciyes University, School of Medicine, Department of Hematology, Dedeman Stem Cell Transplantation Hospital, Kayseri, Turkey Phone: +90 352 437 49 37 E-mail:
| | - Bülent Eser
- Erciyes University, School of Medicine, Department of Hematology, Dedeman Stem Cell Transplantation Hospital, Kayseri, Turkey
| | - Leylagül Kaynar
- Erciyes University, School of Medicine, Department of Hematology, Dedeman Stem Cell Transplantation Hospital, Kayseri, Turkey
| | - Fatih Kurnaz
- Erciyes University, School of Medicine, Department of Hematology, Dedeman Stem Cell Transplantation Hospital, Kayseri, Turkey
| | - Hülya Şıvgın
- Erciyes University, School of Medicine, Department of Medical Genetics, Kayseri, Turkey
| | - Süleyman Yazar
- Erciyes University, School of Medicine, Department of Parasitology, Kayseri, Turkey
| | - Mustafa Çetin
- Erciyes University, School of Medicine, Department of Hematology, Dedeman Stem Cell Transplantation Hospital, Kayseri, Turkey
| | - Ali Ünal
- Erciyes University, School of Medicine, Department of Hematology, Dedeman Stem Cell Transplantation Hospital, Kayseri, Turkey
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45
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Trifilio SM, Pi J, Mehta J. Changing epidemiology of Clostridium difficile-associated disease during stem cell transplantation. Biol Blood Marrow Transplant 2012; 19:405-9. [PMID: 23219779 DOI: 10.1016/j.bbmt.2012.10.030] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Accepted: 10/26/2012] [Indexed: 12/31/2022]
Abstract
The incidence and severity of Clostridium difficile-associated disease (CDAD) within the general population has risen dramatically over the past decade, yet little data are available from hematopoietic stem cell transplantation (HSCT) centers. In the present study, we performed a chart review of 822 consecutive autologous and allogeneic HCST recipients treated at Northwestern Memorial Hospital between 2004 and 2008 to determine the incidence of CDAD at our institution. Variables including age, sex, diagnosis, chemotherapy regimen, transplantation type, microbial colonization, coinfections, diet, antibiotic use, neutropenic fever, comorbid conditions, time to engraftment, growth factor administration, and occurrence of graft-versus-host disease were assessed as potential risk factors for the development of CDAD. Eighty-five CDAD cases (10.3%) were identified. Bivariate analysis revealed a significant association between CDAD and neutropenic fever, administration of a neutropenic diet, ciprofloxacin and aztreonam use and duration of therapy, vancomycin and aztreonam use and duration of therapy, receipt of an allogeneic transplantation, bacterial coinfection, and vancomycin-resistant Entereococcus faecium (VRE) colonization. Cox regression analysis identified the following as factors associated with the development of CDAD: age >60 years, allogeneic transplantation, and prior VRE colonization. Allogeneic recipients with CDAD experienced increased higher rates of grades II to IV gastrointestinal graft-versus-host disease and nonrelapse mortality. A risk stratification model was developed to identify HSCT recipients at different levels of risk. With an incidence >10%, CDAD is a significant infectious complication of stem cell transplantation.
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Affiliation(s)
- Steven M Trifilio
- Feinberg School of Medicine, Northwestern University, 250 E. Superior Street, Chicago, IL 60611, USA.
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46
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Neemann K, Eichele DD, Smith PW, Bociek R, Akhtari M, Freifeld A. Fecal microbiota transplantation for fulminant Clostridium difficile infection in an allogeneic stem cell transplant patient. Transpl Infect Dis 2012; 14:E161-5. [PMID: 23121625 DOI: 10.1111/tid.12017] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 04/29/2012] [Accepted: 07/04/2012] [Indexed: 12/12/2022]
Abstract
We present a case of severe Clostridium difficile infection (CDI) in a non-neutropenic allogeneic hematopoietic stem cell transplant recipient who was treated successfully with fecal microbiota therapy after standard pharmacologic therapy had failed. Following naso-jejunal instillation of donor stool, the patient's symptoms resolved within 48 h. Bowel resection was averted. This is the first case in the literature, to our knowledge, to describe fecal microbiota therapy in a profoundly immunocompromised host with severe CDI. We propose that fecal microbiota therapy be considered as a therapeutic option in immunosuppressed patients with refractory severe CDI.
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Affiliation(s)
- K Neemann
- Infectious Diseases Division, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA.
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47
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Abstract
Diarrhea is a common problem in patients with immunocompromising conditions. The etiologic spectrum differs from patients with diarrhea who have a normal immune system. This article reviews the most important causes of diarrhea in immunocompromised patients, ranging from infectious causes to noninfectious causes of diarrhea in the setting of HIV infection as a model for other conditions of immunosuppression. It also deals with diarrhea in specific situations, eg, after hematopoietic stem cell or solid organ transplantation, diarrhea induced by immunosuppressive drugs, and diarrhea in congenital immunodeficiency syndromes.
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Affiliation(s)
- Elisabeth Krones
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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48
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Robles JDF, Cheuk DKL, Ha SY, Chiang AKS, Chan GCF. Norovirus infection in pediatric hematopoietic stem cell transplantation recipients: incidence, risk factors, and outcome. Biol Blood Marrow Transplant 2012; 18:1883-9. [PMID: 22796532 DOI: 10.1016/j.bbmt.2012.07.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 07/05/2012] [Indexed: 10/28/2022]
Abstract
Norovirus infections are increasingly being recognized as important causes of diarrhea in hematopoietic stem cell transplantation (HSCT) recipients. This retrospective study aimed to evaluate the cumulative incidence, risk factors, and outcomes of norovirus infection in pediatric HSCT recipients. Among 55 patients age <21 years who underwent first HSCT between July 2007 and June 2011, 49 patients developed diarrhea and had stool tested for norovirus. Eight of these patients were found to be infected with norovirus. All were sporadic cases and manifested with nausea, vomiting, and diarrhea. The median age of these patients was 5.2 years (range, 0.5-18.5 years). Six were males. Seven patients underwent unrelated donor HSCT, and 1 patient underwent autologous cord blood HSCT. Two patients had norovirus infection before HSCT that persisted after transplantation. In the remaining 6 patients, norovirus developed at a median of 36.5 days posttransplantation (range, 5-517 days). The cumulative incidence of norovirus infection was 12.9% at 2 years posttransplantation. Risk factors for norovirus infection included the use of peripheral blood or cord blood as the stem cell source (P = .043) and administration of fludarabine (P = .002) and alemtuzumab (P = .011). The median time to viral clearance was 145 days (range, 13-263 days). Four-year survival was similar in norovirus-infected patients and noninfected patients (56.3% versus 58.3%).
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Affiliation(s)
- Joseph Delano F Robles
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
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49
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Alonso CD, Treadway SB, Hanna DB, Huff CA, Neofytos D, Carroll KC, Marr KA. Epidemiology and outcomes of Clostridium difficile infections in hematopoietic stem cell transplant recipients. Clin Infect Dis 2012; 54:1053-63. [PMID: 22412059 DOI: 10.1093/cid/cir1035] [Citation(s) in RCA: 164] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background. Clostridium difficile is the leading cause of infectious diarrhea among hospitalized patients and is a major concern for patients undergoing hematopoietic stem cell transplantation (HSCT). Risk factors and the natural history of C. difficile infection (CDI) are poorly understood in this population. Methods. We performed a retrospective nested case-control study to describe the epidemiology, timing, and risk factors for CDI among adult patients who received HSCTs at our center from January 2003 through December 2008. Results. The overall 1-year incidence of CDI was 9.2% among HSCTs performed (n = 999). The median time to diagnosis of CDI was short among both autologous and allogeneic HSCT recipients (6.5 days and 33 days, respectively). Risk factors for CDI in allogeneic HSCT recipients included receipt of chemotherapy prior to conditioning for HSCT, broad-spectrum antimicrobial use, and acute graft-versus-host disease (GVHD; adjusted odds ratio [AOR], 4.45; 95% confidence interval [CI], 1.54-12.84; P = .006). There was a strong relationship between early CDI and subsequent development of gastrointestinal tract GVHD in the year following allogeneic HSCT (P < .001). Gastrointestinal GVHD was also strongly associated with an increased risk for recurrent CDI (AOR, 4.23 [95% CI, 1.20-14.86]; P = .02). Conclusions. These results highlight the high incidence and early timing of CDI after HSCT. Early timing, coupled with the noted risk of pretransplant chemotherapy, suggests that the natural history of disease in some patients may involve colonization prior to HSCT. A potentially important interplay between CDI and GVHD involving the gastrointestinal tract was observed.
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Affiliation(s)
- Carolyn D Alonso
- Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD 21205, USA
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50
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Collini PJ, Bauer M, Kuijper E, Dockrell DH. Clostridium difficile infection in HIV-seropositive individuals and transplant recipients. J Infect 2012; 64:131-47. [PMID: 22178989 DOI: 10.1016/j.jinf.2011.12.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 12/03/2011] [Accepted: 12/06/2011] [Indexed: 12/16/2022]
Abstract
Immunocompromise is a commonly cited risk factor for Clostridium difficile infection (CDI). We reviewed the experimental and epidemiological literature on CDI in three immunocompromised groups, HIV-seropositive individuals, haematopoietic stem cell or bone marrow transplant recipients and solid organ transplant recipients. All three groups have varying degrees of impairment of humoral immunity, a major factor influencing the outcome of CDI. Soluble HIV proteins such as nef and immunosuppressive agents such as cyclosporin, azathioprine and mycophenalate mofetil modify signalling from the key cellular pathways triggered by C. difficile toxin A, although there is a paucity of data on how these factors may interact with pathways activated by toxin B. Despite this, there has been little direct investigation into the effect of immunosuppression on the pathogenesis of CDI. Epidemiological studies consistently show increased rates of CDI in these populations, which are higher in those with greater degrees of immunocompromise such as individuals with advanced AIDS not receiving combination antiretroviral therapy or allogeneic haematopoietic stem cell transplant recipients. Less consistently data suggests immunocompromise in each group also impacts rates of severe, recurrent or complicated CDI. However all these conditions are characterised by high levels of antibiotic use and prolonged hospital stay, both powerful drivers of CDI risk.
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Affiliation(s)
- Paul J Collini
- Department of Infection and Immunity, University of Sheffield Medical School and Sheffield Teaching Hospitals, Beech Hill Rd, Sheffield S10 2RX, UK.
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