Surveillance of nosocomial infections in adult recipients of allogeneic and autologous bone marrow and peripheral blood stem-cell transplantation

Multiple myeloma and infections in the era of novel treatment modalities

Infections are major cause of morbidity and mortality in patients with multiple myeloma. Current treatment landscape of newly-diagnosed multiple myeloma includes different classes of drugs, such as proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies, all of which are characterized by specific risk and pattern of infectious complications. Additionally, autologous and allogeneic hematopoietic cell transplantation, widely used in the treatment of multiple myeloma, are complex procedures, carrying a significant risk of complications, and mainly infections. Finally, novel treatment modalities such as bispecific T-cell engagers and chimeric antigen receptor T-lymphocytes have been changing the paradigm of myeloma treatment in relapsed-refractory setting. These agents due to unique mechanism of action carry distinct pattern of infectious complications. In this review, an attempt has been made to summarize the incidence, risk factors, and patterns of infections during different stages of myeloma treatment including novel treatment modalities, and to provide evidence underlying the current concept of infectious disease prophylaxis in this category of patients.

Hospital-acquired bloodstream infections in patients with cancer: current knowledge and future directions

Patients with cancer experience higher rates of preventable harm from hospital-acquired bloodstream infections (haBSIs) and central-line-associated bloodstream infections (CLABSIs) compared with the general hospital population. The prevention of haBSIs and CLABSIs in patients with cancer is an urgent priority, and requires standardized surveillance and reporting efforts. The application of haBSI and CLABSI definitions, classification systems and surveillance strategies for patients with cancer is complex, and there is wide variation in clinical practice. Existing systems were not designed explicitly for patients with cancer, and have different strengths and weaknesses in the cancer setting. For these reasons, epidemiological estimates of haBSIs and CLABSIs in patients with cancer also require careful interpretation. This complexity can be a barrier to identifying appropriate targets for intervention and reducing preventable harm. This review provides an overview of key concepts and challenges in haBSI surveillance and prevention specific to patients with cancer. In addition, this review summarizes the strengths and weaknesses of commonly used surveillance definitions and denominators in the setting of cancer care; existing surveillance practice; epidemiology of haBSIs and CLABSIs; prevention strategies; and current knowledge gaps. A global collaborative effort to harmonize the surveillance of hospital-acquired infections in patients with cancer would be invaluable to improve the accuracy and utility of existing data, advance efforts to prevent hospital-acquired infections, and improve patient safety.

Infection prevention requirements for the medical care of immunosuppressed patients: recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute

In Germany, guidelines for hygiene in hospitals are given in form of recommendations by the Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, "KRINKO"). The KRINKO and its voluntary work are legitimized by the mandate according to § 23 of the Infection Protection Act (Infektionsschutzgesetz, "IfSG"). The original German version of this document was published in February 2021 and has now been made available to the international professional public in English. The guideline provides recommendations on infection prevention and control for immunocompromised individuals in health care facilities. This recommendation addresses not only measures related to direct medical care of immunocompromised patients, but also management aspects such as surveillance, screening, antibiotic stewardship, and technical/structural aspects such as patient rooms, air quality, and special measures during renovations.

The insertion site is the main risk factor for central venous catheter-related complications in patients with hematologic malignancies

Central venous catheters (CVC) placed either via the internal jugular vein (IJV) or the subclavian vein (SCV) are routinely used in patients with hematologic malignancies. In this retrospective study, we systematically compared CVC-associated complications for both insertion sites, IJV and SCV. Between January 2011 and June 2013, all consecutive patients (n = 87) were included with at least one CVC (n = 153; n = 94 IJV; n = 59 SCV) at our institution due to induction/consolidation for AML/ALL or autologous hematopoietic cell transplantation (HCT). Primary study endpoints were central line-associated (CLABSI), catheter-related (CRBSI) blood stream infections and local inflammation (LI) at the insertion site. CRBSI occurred earlier and more frequently in the IJV- versus the SCV-group with an incidence rate of CRBSI at day 15 of 10% versus 0% (p = .04) and a rate of CRBSI per 1000 CVC days of 5.7 versus 1.2. In addition, CLABSI was detected more often in IJV- compared to SCV-CVC (26% vs. 8%, p = .009). Conversely, LI occurred more frequently and earlier in SCV- versus IJV-CVC (88% vs. 56%, p < .0001) with a median time to LI of 9 versus 14 days (p < .0001). The strongest risk factor for the endpoints CRBSI, CLABSI, and LI was the insertion site. However, SCV insertion was a risk factor for LI (p = .001, HR: 2.0), insertion in the IJV a risk factor for CLABSI (p = .044, HR: 2.7) and CRBSI (p = .036, HR: 5.4). These results demonstrate a differential effect of the insertion site of CVC in neutropenic patients with a significantly reduced frequency of CVC-related blood stream infections in SCV-CVC.

Evaluation of healthcare-associated infection rates in patients with hematologic malignancies and stem cell transplantation during the coronavirus disease 2019 (COVID-19) pandemic

Objective

To evaluate whether rates of healthcare-associated infections (HAIs) changed during the coronavirus disease 2019 (COVID-19) pandemic in malignant hematology and stem cell transplant patients.

Design

A retrospective, cohort study.

Patients

The study included malignant hematology and stem cell transplant patients admitted between March 1, 2019, through July 31, 2019, and March 1, 2020, through July 31, 2020.

Methods

Rates of catheter-associated urinary tract infections (CAUTIs), central-line-associated bloodstream infections (CLABSIs), central-line-associated mucosal barrier injury infections (CLAMBIs), and Clostridioides difficile infections (CDIs) during the pandemic were compared to those in a control cohort. Secondary outcomes included the rate of non-COVID-19 respiratory viruses.

Results

The rate of CAUTIs per 1,000 hospital days was 0.435 before the pandemic and 0.532 during the pandemic (incidence rate ratio [IRR], 1.224; 95% confidence interval [CI], 0.0314-47.72; P = .899). The rate of CLABSIs was 0.435 before the pandemic and 1.064 during the pandemic (IRR, 2.447; 95% CI, 0.186-72.18; P = .516). The rate of CLAMBIs was 2.61 before the pandemic and 1.064 during the pandemic (IRR 0.408, 95% CI 0.057-1.927; P = .284). The rate of CDIs was 2.61 before the pandemic and 1.579 during the pandemic (IRR, 0.612; 95% CI, 0.125-2.457; P = .512). Non-COVID-19 respiratory virus cases decreased significantly from 12 (30.8%) to 2 cases (8.3%) (P = 0.014).

Conclusions

There was no significant difference in HAIs among inpatient malignant hematology and stem cell transplant patients during the COVID-19 pandemic compared to those of a control cohort. Rates of infection were low among both cohorts. Rates of community-acquired respiratory viruses decreased significantly during the pandemic among this population.

Epidemiological surveillance of health care-associated infections in a pediatric hematopoietic stem cell transplantation unit in South Brazil

BACKGROUND

Pediatric hematopoietic stem cell transplantation (HSCT) recipients represent a vulnerable population with regard to health care-associated infections (HAI) with a differentiated profile of etiologic agents.^1,2 There are few reports in the literature regarding HAI in the pediatric population submitted to HSCT.

METHODS

This is a retrospective study conducted in a pediatric HSCT unit in Curitiba, Brazil between February 2013 and December 2017 that evaluated 109 pediatric patients. The variables analyzed were: age, gender, baseline disease, type of transplantation, infection topography, etiologic agent, time of HAI occurrence, antimicrobial prophylaxis, period of neutropenia, length of stay, and outcomes RESULTS: Of 113 HSCT procedures, 91 (83.5%) were allogenic and 18 were autologous (16.5%). The mean age of the patients was 7.9 years, with a median of 8.1 years (4.0 months-17.3 years); 71 (65.1%) were male; 55 (50.5%) presented with an oncologic diagnosis, 32 (29.4%) with a hematological diagnosis, 17 (15.6%) with immunodeficiencies, and 5 (4.6%) with other causes. During hospitalization after HSCT, 86 episodes of HAI were detected in 66 patients, with an infection density of 16.5 infections/1000 patient days, 86% of which occurred after allogeneic transplants, appearing, on average, 15.3 days after transplantation. The main topographies were bloodstream infection (BSI), with 24 (27.9%) cases, and central line-associated bloodstream infection (CLABSI), with 11 (12.8%). Gram-positive bacteria predominated in cultures and HAI was more frequent in patients diagnosed with immunodeficiencies and other non-oncologic and non-hematologic conditions. Among the Gram-positive bacteria, Staphylococcus epidermidis was the main agent identified (77.7%), possibly because of colonization. However, Gram-negative bacteria, with a resistance profile, comprised 40% of the cases of bacterial infections, most of them represented by Klebsiella pneumoniae (66.6%). Of the 66 patients who presented HAI, 59 patients (89.4%) were discharged, and 7 (10.6%) died.

CONCLUSION

The main topographies were CLABSI and BSI. Patients with immunodeficiencies presented a higher risk for HAI Staphylococcus epidermidis was the main agent identified. However, Klebsiella pneumoniae posed a higher risk for Pediatric Intensive Care Unit admission and death.

Influence of the Insertion Site on Central Venous Catheter-Related Complications in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation

Central venous catheters (CVCs) are extensively used in patients undergoing allogeneic hematopoietic cell transplantation (HCT). In these patients CVC are placed routinely either via the internal jugular vein (IJV) or the subclavian vein (SCV). Purpose of this study was to systematically analyze complications of CVC at different insertion sites in HCT recipients. In this retrospective analysis, all consecutive patients (n = 56) who received a CVC (n = 101) due to allogeneic HCT at our institution between January 2011 and June 2013 were included. Three-lumen standard, nontunneled CVCs were placed via either the IJV (n = 60; 59%) or the SCV (n = 41; 41%). Study endpoints were time to local inflammation at the insertion site, time to fever, time to a combined endpoint of inflammation and fever, central line-associated bloodstream infection (CLABSI), duration of catheterization, catheter lumen obstruction, deep-vein thrombosis, pneumothorax, and catheter-related death. The median duration of catheterization per CVC was almost identical for the IJV and SCV sites (18 days versus 17 days; P not significant). There were no differences in the frequency of CLABSI, deep-vein thrombosis, pneumothorax, and catheter lumen obstruction between IJV and SCV CVC insertion sites. None of the patients died due to a CVC-related cause. Local inflammation occurred less frequently (48% versus 71%; P = .025) and later (median time to local inflammation, 25 days versus 12 days; P = .01) in IJV CVCs versus SCV CVCs. There was a trend toward a median longer time to the occurrence of fever for IJV CVCs compared with SCV CVCs (20 days versus 13 days; P = .07). In the multivariate analysis, diagnosis of acute leukemia (hazard ratio [HR], 1.696; P = .036), SCV CVC (HR, 1.617; P  = .039), and neutropenic CVC-days (HR, 2.477; P = .01) were identified as risk factors for the occurrence of local inflammation or fever. In contrast to earlier studies in patients without hematologic malignancies, these data demonstrate that CVCs placed in the SCV are not superior over IJV CVCs. Moreover, local inflammation occurred earlier and more frequently in patients with an SCV CVC.

Is hospital-acquired pneumonia different in transplant recipients?

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are serious complications in transplant patients. The aim of this review is to summarize the evidence regarding nosocomial pneumonia in transplant recipients, including HAP in non-ventilated patients and VAP, and to identify future directions for improvement.A comprehensive literature search in the PubMed/MEDLINE database was performed. Articles written in English and published between 1990 and November 2018 were included. HAP/VAP in transplant patients usually occurs early post-transplant, particularly during neutropenia in haematopoietic stem cell transplant recipients. Bacteria are the leading cause of nosocomial pneumonia for both immunocompetent and transplant recipients, being Gram negative organisms, and especially Pseudomonas aeruginosa, highly prevalent. Multidrug-resistant bacteria are of special concern. Pneumonia in the transplant setting may be caused by opportunistic pathogens, and the differential diagnosis needs to be extended to other non-infectious complications. The most relevant opportunistic pathogens are Aspergillus fumigatus, Pneumocystis jirovecii and cytomegalovirus. Nevertheless, they are an exceptional cause of nosocomial pneumonia, and usually occur in severely immunosuppressed patients not receiving antimicrobial prophylaxis. Performing bronchoalveolar lavage may improve the rate of aetiological diagnosis, leading to a change in therapeutic management and improved outcomes. The optimal length of antibiotic therapy for bacterial HAP/VAP has not been well defined, but it should perhaps be longer than in the general population. Mortality associated with HAP/VAP is high. HAP/VAP in transplant patients is frequent and is associated with increased mortality. There is room for improvement in gaining knowledge about the management of HAP/VAP in this population.

Granulocyte colony-stimulating factor utilization postautologous hematopoietic stem cell transplant in multiple myeloma patients: Does one size fit all?

PURPOSE

To evaluate a single institution's experience with granulocyte colony-stimulating factor after autologous hematopoietic stem cell transplant in myeloma patients to identify populations that benefit most from granulocyte colony-stimulating factor administration.

METHODS

Retrospective chart reviews were conducted on patients 18+ years with multiple myeloma that underwent autologous hematopoietic stem cell transplant at UW Health from January 2012 to May 2016. Data collection included demographics, length of stay, time to engraftment, Eastern Cooperative Oncology Group performance status score, and hematopoietic cell transplantation-comorbidity index. The primary outcome was days from transplant to engraftment, defined as absolute neutrophil count  > 500/mm³ for two consecutive days or absolute neutrophil count > 1000/mm³ once. A subset analysis was performed on patients whose date of engraftment was known.

RESULTS

In total, 216 individual patients were included in the full cohort and 122 patients included in the subset analysis. Median time to engraftment between patients administered granulocyte colony-stimulating factor and the nongranulocyte colony-stimulating factor group was 12 versus 19 days (P < 0.001) in the full cohort and 12 versus 14 days (P < 0.001) in the subset analysis. The average length of stay posthematopoietic stem cell transplant in the granulocyte colony-stimulating factor group was 15 days versus 17 days in the nongranulocyte colony-stimulating factor group (P = 0.026) in the subset analysis. Additionally, no difference in time to engraftment was seen when stratified by age, Eastern Cooperative Oncology Group performance status score, or hematopoietic cell transplantation-comorbidity index.

CONCLUSION

Our study supports use of granulocyte colony-stimulating factor posthematopoietic stem cell transplant in myeloma patients to decrease time to engraftment and length of stay. Consideration should be given to utilization in all patients in this population posthematopoietic stem cell transplant. Further research is needed to identify the populations that benefit most from granulocyte colony-stimulating factor administration.

Impact of fluoroquinolone prophylaxis during neutropenia on bloodstream infection: Data from a surveillance program in 8755 patients receiving high-dose chemotherapy for haematologic malignancies between 2009 and 2014

OBJECTIVES

Antibacterial chemoprophylaxis with fluoroquinolones (FQPx) has been commonly used in cancer patients with neutropenia, but its efficacy has been challenged by the emergence of fluoroquinolone resistance.

METHODS

The impact of FQPx on bloodstream infections (BSI) during neutropenia after high-dose chemotherapy for haematologic malignancies was evaluated through a multicenter hospital infection surveillance system for the period 2009-2014.

RESULTS

Among 8755 patients (4223 allogeneic [allo-] HSCT, 3602 autologous [auto-] HSCT, 930 high-dose chemotherapy for acute leukemia [HDC]), 5302 (61%) had received FQPx. Administration of FQPx was associated with fewer Gram-negative BSI in the overall study cohort patients (4.6% vs. 7.7%, adjusted subdistribution hazard ratio [aSHR] 0.59, 95%CI 0.50-0.70), in patients with HDC (3.7% vs. 9.2%, adjusted subdistribution hazard ratio [aSHR] 0.40, 95%CI 0.22-0.70) and auto-HSCT patients (4% vs. 9%, aSHR 0.43, 95%CI 0.33-0.56). In HDC patients, FQPx was associated with a marked reduction in all-cause mortality during neutropenia (2.3% vs. 7.8%, aSHR 0.30, 95%CI 0.15-0.58). Patients receiving FQPx had significantly more BSIs due to ESBL-positive Enterobacteriacea (0.8 vs. 0.3%, RR 2.2, 95%CI 1.17-4.26). BSIs by MRSA (n = 5) and VRE (n = 11) were rare in our cohort.

CONCLUSIONS

As used in the participating centers, FQPx was associated with reduced Gram-negative BSI and improved survival among HDC patients. Among HSCT patients, the benefits were less clear. If adapted to local resistance patterns and patient characteristics, FQPx still may be useful in the management of patients with haematologic malignancies.

Diagnosis and management of gastrointestinal complications in adult cancer patients: 2017 updated evidence-based guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Cancer patients frequently suffer from gastrointestinal complications. In this manuscript, we update our 2013 guideline on the diagnosis and management of gastrointestinal complications in adult cancer patients by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). An expert group was put together by the AGIHO to update the existing guideline. For each sub-topic, a literature search was performed in PubMed, Medline, and Cochrane databases, and strengths of recommendation and the quality of the published evidence for major therapeutic strategies were categorized using the 2015 European Society for Clinical Microbiology and Infectious Diseases (ESCMID) criteria. Final recommendations were approved by the AGIHO plenary conference. Recommendations were made with respect to non-infectious and infectious gastrointestinal complications. Strengths of recommendation and levels of evidence are presented. A multidisciplinary approach to the diagnosis and management of gastrointestinal complications in cancer patients is mandatory. Evidence-based recommendations are provided in this updated guideline.

Infection surveillance in pediatric hematopoietic stem cell transplantation recipients

OBJECTIVE

To describe the profile of reported healthcare-associated infections (HAIs) in pediatric patients submitted to hematopoietic stem cell transplantation (HSCT) at a reference center.

METHODS

Retrospective cohort of pediatric patients who were submitted to HSCT from 2008 to 2016. The criteria for HAI were based on those established by the National Healthcare Safety Network. Data were collected by active surveillance performed daily by professionals. This study was approved by the institutional research ethics committee.

RESULTS

A total of 86 HSCTs were performed in 81 patients younger than 18 years of age (median, 10 years). Of these, 69 (85%) were males. Aplastic anemia and leukemia were the main diagnoses. A total of 140 HAIs were diagnosed with an incidence density of 28.2 infections/1000 patient-days. The most common HAI was laboratory-confirmed bloodstream infection (46), the majority of which was reported to be central venous catheter-associated (43). Gram-negative bacteria were the most prevalent microorganisms (58.5%). Almost all the infections occurred until 30 days after transplantation, and 17 deaths were observed within 180 days after the procedure.

CONCLUSION

Active surveillance of HAIs in HSCT children allowed the evaluation of the incidence and profile of HAIs, which is essential for the health care of these patients.

Antibacterial Resistance in Patients with Hematopoietic Stem Cell Transplantation

Recipients of hematopoietic stem cell transplantation (HSCT) are at substantial risk of bacterial, fungal, viral, and parasitic infections depending on the time elapsed since transplantation, presence of graft-versus-host disease (GVHD), and the degree of immunosuppression. Infectious complications in HSCT recipients are associated with high morbidity and mortality. Bacterial infections constitute the major cause of infectious complications, especially in the early post-transplant period. The emergence of antibacterial resistance complicates the management of bacterial infections in this patient group. Multidrug-resistant bacterial infections in this group of patients have attracted considerable interest and may lead to significant morbidity and mortality. Empirical antibacterial therapy in patients with HSCT and febrile neutropenia has a critical role for survival and should be based on local epidemiology. This review attempts to provide an overview of risk factors and epidemiology of emerging resistant bacterial infections and their management in HSCT recipients.

Masks for prevention of respiratory viruses on the BMT unit: results of a quality initiative

Respiratory viral infections (RVI) cause significant morbidity and mortality in hospitalized oncology patients. These viruses are easily spread from asymptomatic and/or symptomatic healthcare workers and visitors to immunocompromised patients, and literature review of facemasks for prevention of infection revealed mixed results. The Bone Marrow Transplant (BMT) Quality Assurance (QA) Committee at Mount Sinai began a surgical mask initiative on the BMT unit. The purpose of our initiative was to assess the impact of surgical mask implementation for healthcare workers and visitors on nosocomial RVI in all patients hospitalized on the BMT unit. We hypothesized that implementing surgical masks would reduce the number of hospital-acquired RVI. We performed a retrospective study involving all patients with malignancy hospitalized on the BMT unit for 4 years. During the latter 2 years, all healthcare workers and visitors were required to wear a surgical mask in every patient room on the BMT unit. Primary endpoint was incidence of RVI after implementation of surgical masks. The 2-year incidence of RVI in the pre-mask period was 14 out of a total of 15 001 patient days on the unit vs 2 out of 15 608 patient days after mask implementation. The difference in incidence of RVI within the two time intervals was noted to be statistically significant (P<.05, 2-proportion z-test). Our quality initiative demonstrated that surgical masks are an infection control modality that may provide benefit to oncology/BMT units by decreasing the risk for hospital-acquired RVI.

Device-Associated Infection Rates for Non–Intensive Care Unit Patients

Background.

Reference data from intensive care units (ICUs) are not applicable to non-ICU patients because of the differences in device use rates, length of stay, and severity of underlying diseases among the patient populations. In contrast to the huge amount of data available for ICU patients, appropriate surveillance data for non-ICU patients have been missing in Germany.

Objective.

To establish a new module (“DEVICE-KISS”) of the German Nosocomial Infection Surveillance System for generating stratified reference data for non-ICU wards.

Setting.

Non-ICU patients from 42 German hospitals.

Methods.

Monthly patient-days, device-days and nosocomial infections (NIs) (using Centers for Disease Control and Prevention definitions) were counted. Device use rates were calculated, and NI rates were stratified by different medical specialities.

Results.

From July 2002 through June 2004, among the 77 wards, there were a total of 536,955 patient-days and 74,188 device-days (for CVC-associated primary bloodstream infections, there were 181,401 patient-days and 8,317 central vascular catheter [CVC]-days in 29 wards; for urinary catheter–associated urinary tract infections, there were 445,536 patient-days and 65,871 urinary catheter–days in 65 wards) and 483 NIs (36 bloodstream infections and 447 urinary tract infections). The mean device use rates were 4.6 device-days per 100 patient-days for CVCs (29 wards) and 14.8 device-days per 100 patient-days for urinary catheters (65 wards), respectively. Mean device-associated NI rates were 4.3 infections per 1,000 CVC-days for CVC-associated bloodstream infections and 6.8 infections per 1,000 urinary catheter–days for catheter-associated urinary tract infections.

Conclusions

DEVICE-KISS allows non-ICUs to recognize an outlier position with regard to NIs by providing well-founded reference data for non-ICU patients.

Central line-associated bloodstream infections in non-ICU inpatient wards: a 2-year analysis

OBJECTIVE

Little is known about patient-specific factors contributing to central line-associated bloodstream infection (CLABSI) outside of the intensive care unit (ICU). We sought to describe these factors and hypothesized that dialysis patients would comprise a significant proportion of this cohort.

DESIGN

Retrospective observational study from January 2010 to December 2011.

SETTING

An 880-bed tertiary teaching hospital.

PATIENTS

Patients with CLABSI in non-ICU wards.

METHODS

CLABSI patients were identified from existing infection-control databases and primary chart review was conducted. National Health and Safety Network (NHSN) definitions were utilized for CLABSI and pathogen classification. CLABSI rates were calculated per patient day. Total mortality rates were inclusive of hospice patients.

RESULTS

Over a 2-year period, 104 patients incurred 113 CLABSIs for an infection rate of 0.35 per 1,000 patient days. The mean length of hospital stay prior to CLABSI was 16±13.3 days, which was nearly 3 times that of hospital-wide non-ICU length of stay. Only 11 patients (10.6%) received dialysis within 48 hours of CLABSI. However, 67% of patients had a hematologic malignancy, and 91.8% of those admitted with a malignant hematologic diagnosis were neutropenic at the time of CLABSI. Enterococcus spp. was the most common organism recovered, and half of all central venous catheters (CVCs) present were peripherally inserted central catheters (PICC lines). Mortality rates were 18.3% overall and 27.3% among dialysis patients.

CONCLUSIONS

In patients with CLABSIs outside of the ICU, only 10.6% received dialysis prior to infection. However, underlying hematologic malignancy, neutropenia, and PICC lines were highly prevalent in this population.

Febrile neutropenic infection occurred in cancer patients undergoing autologous peripheral blood stem cell transplantation

OBJECTIVE

The objective of this study was to investigate the incidence, risk factors, and clinical and prognostic characteristics of febrile infection that occurred during the neutropenic period in cancer patients who underwent autologous peripheral blood stem cell transplantation (APBSCT).

METHODS

Clinical data of all the APBSCT cases from 2007 to 2009 in Sun Yat-sen University Cancer Center were collected and retrospectively analyzed.

RESULTS

Eighty-nine APBSCT subjects were investigated. Neutropenia usually occurred on the 4th day (range, 0-15) after transplantation and lasted 6 (range, 3-27) days. Febrile neutropenia occurred in 78.7% patients and lasted around 3 (range, 1-20) days and no infection-related deaths were observed. For febrile episodes, 12 patients (17.1%) were diagnosed as having microbiologically documented infections (MDI). Initial empirical antimicrobial therapy was given to all cases of post-APBSCT febrile neutropenia, of which 44 cases (62.9%) were effective. Febrile neutropenia occurred in 25/34 (73.5%) patients who were given antifungal drugs for prophylaxis.

CONCLUSIONS

Neutropenic infection is still the major complication in APBSCT patients and duration of neutropenia is one of the major risk factors. Prophylactic administration of antifungal drugs seems to be invalid to reduce post-APBSCT infection. Sufficient doses of broad-spectrum antibiotics at the early stage lead to better results of initial antimicrobial treatment.

Current practices used for the prevention of central venous catheter-associated infection in hematopoietic stem cell transplantation recipients: a survey from the Infectious Diseases Working Party and Nurses' Group of EBMT

BACKGROUND

Central line-associated bloodstream infection (CLABSI) is one of the most common infectious complications after hematopoietic stem cell transplantation. To prevent this complication, international guidelines recommend the implementation of the CLABSI 'prevention bundle' consisting of hand hygiene, full barrier precautions, cleaning the insertion site with chlorhexidine, avoiding femoral sites for insertion, and removing unnecessary catheters. The aim of this survey was to analyze to what extent European Group for Blood and Marrow Transplantation (EBMT) centers have included the CLABSI prevention bundle in practice.

METHODS

A questionnaire used for data collection was sent to the 545 EBMT centers worldwide, 103 of which responded.

RESULTS

All 5 components of the CLABSI prevention bundle were recorded in 28% of the centers' standard operating procedures (SOP), and 21% of the centers answered that they used all of the bundle components in clinical practice. The most common recommendation absent from the SOP was specification of all the components of full barrier precautions (43% of the centers did not include at least 1 component). Skin disinfection with chlorhexidine before catheter insertion was reported by 66% centers. CLABSI rates were monitored in 21% of centers.

CONCLUSIONS

Although most of the centers lacked 1 or more of the CLABSI prevention bundle components in their SOP, improvements could easily be made by updating the centers' SOP. The first important step is introduction of CLABSI rate monitoring in this high-risk patient population.

Prediction of central venous catheter-related bloodstream infections (CRBSIs) in patients with haematologic malignancies using a modified Infection Probability Score (mIPS)

The aim of this study was to predict the probability of central venous catheter-related bloodstream infections (CRBSIs) in patients with haematologic malignancies using a modified version of the Infection Probability Score (mIPS). In order to perform a prospective, mono-centric surveillance of complications in clinical routine due to short-term central venous catheters (CVCs) in consecutive patients receiving chemotherapy from March 2013 to September 2014, IPS was calculated at CVC insertion and removal (mIPSin and mIPSex, respectively). We used the 2012 Infectious Diseases Working Party of the German Society of Haematology and Medical Oncology (AGIHO/DGHO) criteria to define CRBSI. In total, 143 patients (mean 59.5 years, 61.4 % male) with 267 triple-lumen CVCs (4044 CVC days; mean 15.1 days, range 1-60 days) were analysed. CVCs were inserted for therapy of acute leukaemia (53.2 %), multiple myeloma (24.3 %) or lymphoma (11.2 %), and 93.6 % were inserted in the jugular vein. A total of 66 CRBSI cases (24.7 %) were documented (12 definite/13 probable/41 possible). The incidence was 16.3/1000 CVC days (2.9/3.1/10.1 per 1000 CVC days for definite/probable/possible CRBSI, respectively). In CRBSI cases, the mIPSex was higher as compared to cases without CRBSI (13.1 vs. 7.1; p < 0.001). The best mIPSex cutoff for CRBSI prediction was 8 points (area under the curve (AUC) = 0.77; sensitivity = 84.9 %, specificity = 60.7 %, negative predictive value = 92.4 %). For patients with an mIPSex ≥8, the risk for a CRBSI was high (odds ratio [OR] = 5.9; p < 0.001) and even increased if, additionally, CVC had been in use for about 10 days (OR = 9.8; p < 0.001). In case other causes of infection are excluded, a mIPSex ≥8 and duration of CVC use of about 10 days predict a very high risk of CRBSI. Patients with a mIPSex <8 have a low risk of CRBSI of 8 %.

Bloodstream infection in paediatric cancer centres--leukaemia and relapsed malignancies are independent risk factors

In a prospective multicentre study of bloodstream infection (BSI) from November 01, 2007 to July 31, 2010, seven paediatric cancer centres (PCC) from Germany and one from Switzerland included 770 paediatric cancer patients (58% males; median age 8.3 years, interquartile range (IQR) 3.8-14.8 years) comprising 153,193 individual days of surveillance (in- and outpatient days during intensive treatment). Broviac catheters were used in 63% of all patients and Ports in 20%. One hundred forty-two patients (18%; 95% CI 16 to 21%) experienced at least one BSI (179 BSIs in total; bacteraemia 70%, bacterial sepsis 27%, candidaemia 2%). In 57%, the BSI occurred in inpatients, in 79% after conventional chemotherapy. Only 56 % of the patients showed neutropenia at BSI onset. Eventually, patients with acute lymphoblastic leukaemia (ALL) or acute myeloblastic leukaemia (AML), relapsed malignancy and patients with a Broviac faced an increased risk of BSI in the multivariate analysis. Relapsed malignancy (16%) was an independent risk factor for all BSI and for Gram-positive BSI.

CONCLUSION

This study confirms relapsed malignancy as an independent risk factor for BSIs in paediatric cancer patients. On a unit level, data on BSIs in this high-risk population derived from prospective surveillance are not only mandatory to decide on empiric antimicrobial treatment but also beneficial in planning and evaluating preventive bundles.

WHAT IS KNOWN

• Paediatric cancer patients face an increased risk of nosocomial bloodstream infections (BSIs). • In most cases, these BSIs are associated with the use of a long-term central venous catheter (Broviac, Port), severe and prolonged immunosuppression (e.g. neutropenia) and other chemotherapy-induced alterations of host defence mechanisms (e.g. mucositis). What is New: • This study is the first multicentre study confirming relapsed malignancy as an independent risk factor for BSIs in paediatric cancer patients. • It describes the epidemiology of nosocomial BSI in paediatric cancer patients mainly outside the stem cell transplantation setting during conventional intensive therapy and argues for prospective surveillance programmes to target and evaluate preventive bundle interventions.

Outcomes of Clostridium difficile infection in hospitalized leukemia patients: a nationwide analysis

BACKGROUND The incidence of Clostridium difficile infection (CDI) has increased among hospitalized patients and is a common complication of leukemia. We investigated the risks for and outcomes of CDI in hospitalized leukemia patients. METHODS Adults with a primary diagnosis of leukemia were extracted from the United States Nationwide Inpatient Sample database, 2005-2011. The primary outcomes of interest were CDI incidence, CDI-associated mortality, length of stay (LOS), and charges. In a secondary analysis, we sought to identify independent risk factors for CDI in leukemia patients. Logistic regression was used to derive odds ratios (ORs) adjusted for potential confounders. RESULTS A total of 1,243,107 leukemia hospitalizations were identified. Overall CDI incidence was 3.4% and increased from 3.0% to 3.5% during the 7-year study period. Leukemia patients had 2.6-fold higher risk for CDI than non-leukemia patients, adjusted for LOS. CDI was associated with a 20% increase in mortality of leukemia patients, as well as 2.6 times prolonged LOS and higher hospital charges. Multivariate analysis revealed that age >65 years (OR, 1.13), male gender (OR, 1.14), prolonged LOS, admission to teaching hospital (OR, 1.16), complications of sepsis (OR, 1.83), neutropenia (OR, 1.35), renal failure (OR, 1.18), and bone marrow or stem cell transplantation (OR, 1.27) were significantly associated with CDI occurrence. CONCLUSIONS Hospitalized leukemia patients have greater than twice the risk of CDI than non-leukemia patients. The incidence of CDI in this population increased 16.7% from 2005 to 2011. Development of CDI in leukemia patients was associated with increased mortality, longer LOS, and higher hospital charges.

Third generation cephalosporin resistant Enterobacteriaceae and multidrug resistant gram-negative bacteria causing bacteremia in febrile neutropenia adult cancer patients in Lebanon, broad spectrum antibiotics use as a major risk factor, and correlation with poor prognosis

INTRODUCTION

Bacteremia remains a major cause of life-threatening complications in patients receiving anticancer chemotherapy. The spectrum and susceptibility profiles of causative microorganisms differ with time and place. Data from Lebanon are scarce. We aim at evaluating the epidemiology of bacteremia in cancer patients in a university hospital in Lebanon, emphasizing antibiotic resistance and risk factors of multi-drug resistant organism (MDRO)-associated bacteremia.

MATERIALS AND METHODS

This is a retrospective study of 75 episodes of bacteremia occurring in febrile neutropenic patients admitted to the hematology-oncology unit at Makassed General Hospital, Lebanon, from October 2009-January 2012. It corresponds to epidemiological data on bacteremia episodes in febrile neutropenic cancer patients including antimicrobial resistance and identification of risk factors associated with third generation cephalosporin resistance (3GCR) and MDRO-associated bacteremia.

RESULTS

Out of 75 bacteremias, 42.7% were gram-positive (GP), and 57.3% were gram-negative (GN). GP bacteremias were mostly due to methicillin-resistant coagulase negative staphylococci (28% of total bacteremias and 66% of GP bacteremias). Among the GN bacteremias, Escherichia coli (22.7% of total, 39.5% of GN organisms) and Klebsiella pneumoniae(13.3% of total, 23.3% of GN organisms) were the most important causative agents. GN bacteremia due to 3GC sensitive (3GCS) bacteria represented 28% of total bacteremias, while 29% were due to 3GCR bacteria and 9% were due to carbapenem-resistant organisms. There was a significant correlation between bacteremia with MDRO and subsequent intubation, sepsis and mortality. Among potential risk factors, only broad spectrum antibiotic intake >4 days before bacteremia was found to be statistically significant for acquisition of 3GCR bacteria. Using carbapenems or piperacillin/tazobactam>4 days before bacteremia was significantly associated with the emergence of MDRO (p < 0.05).

CONCLUSION

Our findings have major implications for the management of febrile neutropenia, especially in breakthrough bacteremia and fever when patients are already on broadspectrum antibiotics. Emergence of resistance to 3GCs and, to a lesser extent, to carbapenems in GN isolates has to be considered seriously in our local guidelines for empiric treatment of febrile neutropenia, especially given that their occurrence was proven to be associated with poorer outcomes.

Nosocomial infection in adult admissions with hematological malignancies originating from different lineages: a prospective observational study

Background

Nosocomial infection (NI) causes prolonged hospital stays, increased healthcare costs, and higher mortality among patients with hematological malignancies (HM). However, few studies have compared the incidence of NI according to the HM lineage.

Objective

To compare the incidence of NI according to the type of HM lineage, and identify the risk factors for NI.

Methods

This prospective observational study monitored adult patients with HM admitted for >48 hours to the General Hospital of the People's Liberation Army during 2010–2013. Attack rates and incidences of NI were compared, and multivariable logistic regression was used to control for confounding effects.

Results

This study included 6,613 admissions from 1,922 patients. During these admissions, 1,023 acquired 1,136 NI episodes, with an attack rate of 15.47% and incidence of 9.6‰ (95% CI: 9.1–10.2). Higher rates and densities of NIs were observed among myeloid neoplasm (MN) admissions, compared to lymphoid neoplasm (LN) admissions (28.42% vs. 11.00%, P<0.001 and 11.4% vs. 8.4‰, P<0.001). NI attack rates in acute myeloid leukemia (AML) and myelodysplastic/myeloproliferative neoplasm (MDS/MPN) were higher than those in MDS (30.69% vs. 20.19%, P<0.001; 38.89% vs. 20.19%, P = 0.003). Attack rates in T/NK-cell neoplasm and B-cell neoplasm were higher than those in Hodgkin lymphoma (15.04% vs. 3.65%; 10.94% vs. 3.65%, P<0.001). Multivariable regression analysis indicated prolonged hospitalization, presence of central venous catheterization, neutropenia, current stem cell transplant, infection on admission, and old age were independently associated with higher NI incidence. After adjusting for these factors, MN admissions still had a higher risk of infection (odds ratio 1.34, 95% CI: 1.13–1.59, P<0.001).

Conclusion

Different NI attack rates were observed for HM from different lineages, with MN lineages having a higher attack rate and incidence than LN lineages. Special attention should be paid to MN admissions, especially AML and MDS/MPN admissions, to control NI incidence.

Management of febrile neutropenia in the era of bacterial resistance

Managing cancer patients with fever and neutropenia must be considered as a medical emergency since any delay in initiating appropriate empirical antibacterial therapy may result in high rates of mortality and morbidity. Emerging antibacterial resistance in bacterial pathogens infecting febrile neutropenic patients complicates management, and choosing the type of empirical antimicrobial therapy has become a challenge. To further complicate the decision process, not all neutropenic patients are in same category of susceptibility to develop severe infection. While low-risk patients may be treated with oral antibiotics in the outpatient setting, high-risk patients usually need to be admitted to hospital and receive parenteral broad-spectrum antibiotics until the neutrophil levels recover. These strategies have recently been addressed in two international guidelines from the Infectious Diseases Society of America (IDSA) and the European Conference on Infections in Leukaemia (ECIL). This review gives a brief overview of current antimicrobial resistance problems and their effects in febrile neutropenic cancer patients by summarizing the suggestions from the IDSA and ECIL guidelines.

Management of sepsis in neutropenic patients: 2014 updated guidelines from the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO)

Sepsis is a major cause of mortality during the neutropenic phase after intensive cytotoxic therapies for malignancies. Improved management of sepsis during neutropenia may reduce the mortality of cancer therapies. Clinical guidelines on sepsis treatment have been published by others. However, optimal management may differ between neutropenic and non-neutropenic patients. Our aim is to give evidence-based recommendations for haematologist, oncologists and intensive care physicians on how to manage adult patients with neutropenia and sepsis.

Etiology, clinical features and outcomes of pre-engraftment and post-engraftment bloodstream infection in hematopoietic SCT recipients

We conducted an observational study to assess the etiology, clinical features and outcomes of bloodstream infection (BSI) in 172 hematopoietic SCT (HCST) recipients. One hundred episodes of BSI in the pre-engraftment period (early onset) were compared with 89 episodes in the post-engraftment phase (late onset). More patients with late-onset BSI received an allogeneic HSCT, had GVHD and had received corticosteroids, whereas patients with early-onset BSI were more likely to have neutropenia, severe mucositis and a central venous catheter (CVC) in place. CVC was the most frequent site of infection, followed by an endogenous source. Pneumonia and gastrointestinal infection were particularly frequent in late-onset BSI, whereas mucositis was more frequent in the early-onset group. Gram-positive organisms predominated over Gram negatives. Streptococcus pneumoniae was more frequent in patients with late-onset BSI. Patients with late-onset BSI presented worse outcomes regarding septic shock, intensive care unit admission and early and overall case-fatality rates. Early-onset BSI was mainly related to the presence of neutropenia, mucositis and CVC, whereas late-onset BSI mainly affected severely immunosuppressed allogeneic HSCT recipients with GVHD and corticosteroids. Late-onset BSI caused high case-fatality rates. BSI due to S. pneumoniae was especially frequent late after transplantation. The development of better vaccination strategies is needed.

Clostridium difficile infection in patients with acute myelogenous leukemia and in patients undergoing allogeneic stem cell transplantation: epidemiology and risk factor analysis

Patients receiving treatment for acute myelogenous leukemia (AML) and recipients of allogeneic stem cell transplantation (aSCT) are at high risk of contracting Clostridium difficile infection (CDI), the most frequently observed nosocomial diarrhea and enterocolitis. Data were retrieved from the prospective Cologne Cohort of Neutropenic Patients. Patients hospitalized for aSCT as well as patients receiving treatment for AML were included in the analysis. Risk factor analysis for the occurrence of CDI was performed by backward-stepwise logistic regression (P < .1). During the period from January 2007 to August 2010, 310 hospitalizations of 152 patients with AML and 229 hospitalizations of 223 patients undergoing aSCT were eligible for analysis. Incidence rates for CDI per 10,000 patient days were 17.9 for AML patients and 27.4 for aSCT recipients. Among AML and aSCT patients, median time from initiation of chemotherapy to CDI was 10 days (range, -8 to 101 days) and 17 days (range, 6 to 79), respectively. Logistic regression identified carbapenem exposure to be associated with development of CDI in AML patients (odds ratio [OR], 2.2) and aSCT recipients (OR, 1.4). In both groups, previous exposure to carbapenems was significantly associated with development of CDI. A follow-up study, assessing the effect of an antibiotic stewardship intervention to decrease the administration of carbapenems in hematological high-risk patients, is warranted.

Predictors of mortality attributable to Clostridium difficile infection in patients with underlying malignancy

PURPOSE

This study aimed at evaluating the clinical severity and treatment outcomes of Clostridium difficile infections (CDI) and identifying predictors associated with mortality in patients with malignancy.

METHODS

A retrospective study was conducted in a teaching hospital from January 2004 to June 2013. The subjects included adult patients (aged ≥ 18 years) receiving treatment for malignancy whose conditions were complicated by CDI. Clinical severity was determined using the guidelines from the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America (SHEA/IDSA). Multivariate logistic regression analysis was performed to identify predictors independently associated with CDI-related mortality.

RESULTS

Of the 5,594 patients treated for malignancy at the Division of Hematology/Oncology during the study period, 61 (1.1%) had CDI complications. CDI-related mortality was 19.7% (12/61). Twenty-seven (44.3%) patients were diagnosed with neutropenia (ANC ≤ 500/mm(3)) at initial CDI presentation. Forty-one patients (67.2%) received antimicrobial therapy for CDI. Based on the SHEA/IDSA guidelines, only 12 patients (19.7%) presented with severe CDI, but 25 (61.0%) patients experienced treatment failure. Multiple logistic regression modeling showed neutropenia to be an independent risk factor for CDI-related mortality (odds ratio, 5.17; 95% confidence interval, 1.24-21.59).

CONCLUSIONS

This study tracked poor CDI treatment outcomes in patients with malignancy and identified neutropenia as a previously unrecognized risk factor of CDI-related mortality. Alternative definitions of severe CDI that include neutropenia might be necessary to more accurately determine clinical severity.

Central venous catheter-related infections in hematology and oncology: 2012 updated guidelines on diagnosis, management and prevention by the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology

BACKGROUND

Cancer patients are at increased risk for central venous catheter-related infections (CRIs). Thus, a comprehensive, practical and evidence-based guideline on CRI in patients with malignancies is warranted.

PATIENTS AND METHODS

A panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) has developed a guideline on CRI in cancer patients. Literature searches of the PubMed, Medline and Cochrane databases were carried out and consensus discussions were held.

RESULTS

Recommendations on diagnosis, management and prevention of CRI in cancer patients are made, and the strength of the recommendation and the level of evidence are presented.

CONCLUSION

This guideline is an evidence-based approach to the diagnosis, management and prevention of CRI in cancer patients.

A retrospective review of metronidazole and vancomycin in the management of Clostridium difficile infection in patients with hematologic malignancies

Background

The incidence and severity of Clostridium difficile infection has significantly increased over the past decade. Although the epidemiology and treatment of C. difficile infection is well elucidated in the non-oncology population, it is poorly understood among cancer patients. This illustrates great concern as the majority of these patients are immunosuppressed, which puts them at higher risk for developing severe disease. Furthermore, suboptimal treatment of C. difficile infection can compromise care of underlying malignancy. Due to limited amount of data, we conducted this study to better ascertain the epidemiology and treatment outcomes of C. difficile infection in a subset of oncology patients at our institution.

Objectives

The primary objective was to assess the incidence and severity of C. difficile infection in patients with hematologic malignancies, including those undergoing hematopoietic stem cell transplant for a hematologic condition. The secondary objectives were to assess: (a) the outcome of C. difficile infection after therapy with metronidazole and/or vancomycin and (b) mortality following C. difficile infection.

Methods

We performed a retrospective study to assess the incidence and severity of C. difficile infection and to evaluate outcomes of therapy with metronidazole and/or vancomycin among adult patients admitted to the Malignant Hematology/Blood and Marrow Transplantation service at our center from January 2009 to 2012.

Results

Of the 390 admitted patients during the 3-year study period, the overall incidence of C. difficile infection was 18.7% ( n = 73). Forty-six patients (63.0%) were deemed to have mild-moderate C. difficile infection. With regards to outcome of therapy, less exposure to antimicrobial agents was significantly associated with a higher resolution rate ( p = 0.0029). Response rates to metronidazole were 53.7%, vancomycin 50%, and combination therapy 38.5%, although no difference in achievement of resolution was found among the three treatment modalities ( p = 0.5533). Older patients were more likely to experience recurrent C. difficile infection ( p = 0.0007). It was found that 55 patients (75.3%) were alive at 6 months.

Conclusions

These results highlight the high incidence of C. difficile infection in a subset of cancer patients at our institution. Although most patients presented with mild-moderate disease, severity of C. difficile infection in cancer patients may be underestimated due to the frequent presence of neutropenia. This study is the first analysis conducted, which directly compares outcomes of C. difficile infection after therapy with metronidazole, vancomycin, or combination therapy exclusively in patients with hematologic malignancies, including those undergoing hematopoietic stem cell transplant for a hematologic condition. We found no difference in treatment outcomes among metronidazole, vancomycin, or combination therapy. The recommendation from the literature to use metronidazole as the initial drug of choice for mild-moderate C. difficile infection is a reasonable option, although the rate of cure is low. This study highlights the critical need for better treatment options, due to suboptimal response rates to current therapy. Larger scale studies are needed to better understand the epidemiology and management of C. difficile infection in this patient population.

Incidence of hospital-acquired pneumonia, bacteraemia and urinary tract infections in patients with haematological malignancies, 2004-2010: a surveillance-based study

Objective

This study charted incidence trends of hospital-acquired (HA) pneumonia, bacteraemia and urinary tract infections (UTI) in a haematology department.

Methods

Prospective surveillance of hospital-acquired infections (HAI) was undertaken in a 42-bed haematology department of a university hospital. All patients hospitalized ≥48 hours between 1^st January 2004 and 31^st December 2010 were included. Definitions of HAI were based on a standardized protocol. The incidence was the number of events per 1000 patient-days at risk; only the first HAI was counted. Multivariate Poisson regression was fitted to assess temporal trends.

Results

Among 3 355 patients (58 063 patient-days at risk) included, 1 055 (31%) had HAI. The incidence of HA pneumonia, HA bacteraemia and HA UTI was respectively 3.3, 12.0 and 2.9 per 1000 patient-days at risk. HA bacteraemia incidence increased by 11% (95% confidence interval: +6%, +15%, P<0.001) per year, independently of neutropenia, central venous catheterization (CVC) and haematological disease. The incidences of HA pneumonia and HA UTI were stable. The most frequently isolated pathogens were Aspergillus spp. (59.2%) for pneumonia, coagulase-negative Staphylococcus (44.2%) for bacteraemia and enterobacteria (60%) for UTI.

Conclusion

The incidence of bacteraemia increased, indicating that factors other than CVC exposure, including chemotherapy with its impact on the immune system, could explain this trend. Further analytic studies are needed to explore the factors that could explain this trend.

Prophylactic administration of doxycycline reduces central venous catheter infections in patients undergoing hematopoietic cell transplantation

Hematopoietic stem cells are generally transfused through a central venous catheter (CVC), which also facilitates administration of medications and intravenous fluids. We had observed a high rate of CVC infections at our Bone Marrow Transplantation (BMT) unit. Accordingly, we evaluated the impact of administration of doxycycline as a prophylactic strategy to reduce CVC infection rates. Data was collected retrospectively on 54 consecutive patients, 26 who received doxycycline (doxycycline group), and we compared their outcomes to a previous cohort of 28 subjects who did not receive doxycycline (comparison group). The groups were comparable in regards to age, gender, transplant type, and CD34 cell dose. No (0%) CVC infection was observed in the doxycycline group, while 5 infection episodes (18%) occurred in 4 patients in the comparison group (p<0.001). Isolated organisms included: Escherichia-coli (EC)=1, coagulase-negative Staphylococcus-spp (CNSS)=2, both EC & CNSS=1. Notwithstanding the non-randomized comparative nature of our study, results suggest that CVC infection rate was reduced significantly after adding doxycycline for prophylaxis. A randomized controlled study is warranted to confirm these findings.

Diagnosis and management of gastrointestinal complications in adult cancer patients: evidence-based guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO)

BACKGROUND

Cancer patients frequently suffer from gastrointestinal complications. However, a comprehensive, practical and evidence-based guideline on this issue is not yet available.

PATIENTS AND METHODS

An expert group was put together by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO) to develop a guideline on gastrointestinal complications in cancer patients. For each subtopic, a literature search was carried out in PubMed, Medline and Cochrane databases and the strength of recommendation and the quality of the published evidence for major therapeutic strategies were categorized using a modification of the 'Infectious Diseases Society of America' criteria. Consensus discussions were held on each of the topics.

RESULTS

Recommendations were made with respect to non-infectious and infectious gastrointestinal complications. For all recommendations, the strength of the recommendation and the level of evidence are presented.

CONCLUSION

This guideline is an evidence-based approach to the diagnosis and management of gastrointestinal complications in cancer patients.

Fecal microbiota transplantation for fulminant Clostridium difficile infection in an allogeneic stem cell transplant patient

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.

Preventive strategies for central line-associated bloodstream infections in pediatric hematopoietic stem cell transplant recipients

BACKGROUND

Few studies have described preventive strategies for central line-associated bloodstream infections (CLABSIs) in pediatric hematopoietic stem cell transplantation (HSCT) recipients.

METHODS

We performed a pilot intervention study in our pediatric HSCT population in 2006-2008 and compared CLABSI rates before and after implementation of preventive strategies (ie, training staff and caregivers in procedures for dressing changes and drawing blood) in the inpatient, outpatient, and non-health care (ie, home) settings. We also studied the pathogens associated with hospital-onset versus community-onset CLABSIs.

RESULTS

During the study period, 90 children (median age, 10 years) underwent HSCT. Fifty-nine children (66%) developed a CLABSI; 18 in the hospital, 27 in the community, and 14 in both settings. After implementation of central line (CL) maintenance care strategies, the overall CLABSI rate declined from 10.03 to 3.00 CLABSIs per 1,000 CL-days (rate ratio, 0.3; 95% confidence interval, 0.2-0.5, P < .0001) and rates declined for both hospital- and community-onset CLABSIs. Gram negative pathogens caused more community-onset (45/65, 69%) than hospital-onset (22/46, 48%) CLABSIs (odds ratio, 2.5; 95% confidence interval, 1.1-5.4; P = .02).

CONCLUSIONS

Standardization of care practices for CL maintenance was associated with a reduction of CLABSIs in our pediatric HSCT population. A multicenter study is needed to confirm these observations.

Clostridium difficile infection in HIV-seropositive individuals and transplant recipients

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.

Clostridium difficile infection in cancer patients and hematopoietic stem cell transplant recipients

Clostridium difficile has become the most common bacterial cause of nosocomial diarrhea. High rates of C. difficile infection (CDI) coupled with increasing morbidity and mortality attributed to CDI have sparked a renewed interest in this disease. Emergence of hypervirulent strains, rising rates of severe and recurrent infection and associated infection control challenges, and diagnostic and therapeutic dilemmas are major issues in the non-oncology population. Scant data on CDI exist in the cancer/transplant population. The purpose of this article is to describe the epidemiology, pathogenesis and management of CDI in patients receiving cancer chemotherapeutic agents, and in hematopoietic stem cell transplant recipients.

Infection Probability Score: a predictor of Clostridium difficile-associated disease onset in patients with haematological malignancy

PURPOSE

to assess the predictive power of three systems: Infection Probability Score, APACHE II and KARNOFSKY score for the onset of Clostridium difficile-associated disease (CDAD) in hematology-oncology patients.

METHODS AND SAMPLE

A retrospective pilot surveillance survey was conducted in the hematology unit of a general hospital in Greece. Data were collected by using an anonymous standardised case-record form. The sample consisted of 102 hospitalized patients.

RESULTS

The majority of the patients (33.3%) suffered from acute myeloid leukemia. The cumulative incidence of CDAD was 10.8% and the incidence rate of C difficile associated diarrhea was 5 per 1000 patient-days (14.2 per 1000 patient-days at risk). Patients with CDAD had twofold higher time of mean length of hospital stay compared with patients without CDAD (38.82 ± 23.88 vs 19.45 ± 14.56 days). Additionally patients with CDAD had received a greater number of different antibiotics compared to those without CDAD (5.18 ± 1.99 vs 2.54 ± 2.13), suffered from diabetes, from non Hodgkin's lymphoma, had a statistically significant higher duration of neutropenia ≥3 days and had received antifungal treatment. The best cutoff value of IPS for the prediction of CDAD was 13 with a sensitivity of 45.5% and a specificity of 82.4%.

CONCLUSIONS

IPS is an early diagnostic test for CDAD detection.

Clostridium difficile-associated disease in allogeneic hematopoietic stem-cell transplant recipients: risk associations, protective associations, and outcomes

The purpose of this study was to evaluate risk factors, protective factors, and outcomes associated with Clostridium difficile-associated disease (CDAD) in allogeneic hematopoietic stem-cell transplant (HSCT) recipients. A case-control study was performed with 37 CDAD cases and 67 controls. In the multivariable logistic regression analysis, receipt of a third or fourth generation cephalosporin was associated with increased risk of CDAD (OR = 4.6, 95% CI 1.6-13.1). Receipt of growth factors was associated with decreased risk of CDAD (OR=0.1, 95% CI 0.02-0.3). Cases were more likely to develop a blood stream infection after CDAD than were controls at any point before discharge (p < 0.001). CDAD cases were more likely than controls to develop new onset graft-vs.-host disease (GVHD) (p < 0.001), new onset severe GVHD (p < 0.001), or new onset gut GVHD (p = 0.007) after CDAD/discharge. Severe CDAD was a risk factor for death at 180 d in multivariable Cox proportional hazards regression (HR=2.6, 95% CI 1.1-6.2). CDAD is a significant cause of morbidity and mortality in allogeneic HSCT patients, but modifiable risk factors exist. Further study is needed to determine the best methods of decreasing patients' risk of CDAD.