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Deshpande A, O'Brien J, Hamilton B, Pappas M. Clinical Characteristics and Risk Factors for Clostridioides difficile Infection in the Hematopoietic Cell Transplantation Population. RESEARCH SQUARE 2024:rs.3.rs-4531064. [PMID: 39041031 PMCID: PMC11261972 DOI: 10.21203/rs.3.rs-4531064/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
Background Hematopoietic cell transplantation (HCT) recipients are at increased risk of developing primary and recurrent Clostridioides difficile infection (CDI). The objective of our study was to characterize the risk factors for primary and recurrent CDI in a large cohort of patients hospitalized for HCT. Methods We conducted a retrospective cohort study of adults who underwent HCT from 2010-2023 to analyze the epidemiology, timing, and risk factors for CDI. We compared patients who developed CDI with those who did not, controlling for patient demographics, comorbidities, transplant factors, medications, and laboratory values. Results Of the 2,725 adults who underwent HCT, 252 (9.3%) developed primary CDI within one-year of transplantation. The incidence was higher among allogenic HCT recipients (17.8%) compared to autologous recipients (4.1%). Independent risk factors for primary CDI included receipt of penicillin antibiotics, prior chemotherapy, and umbilical cord stem cells. Receipt of macrolide antibiotics was an independent risk factor for recurrent CDI, while receipt of autologous HCT was associated with a reduced risk of both primary and recurrent CDI. Conclusions CDI presents an early complication after HCT, particularly in allogenic recipients who experience higher incidence rates and severe complications. Early recognition and management of these risk factors are essential to prevent these adverse outcomes.
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Castillo Almeida NE, Gomez CA. Acute diarrhea in the hospitalized immunocompromised patient: what is new on diagnostic and treatment? Curr Opin Crit Care 2024:00075198-990000000-00195. [PMID: 39034915 DOI: 10.1097/mcc.0000000000001191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
PURPOSE OF THIS REVIEW This article aims to provide an intuitive framework for diagnosing and managing healthcare-associated diarrhea (HCAD) in the immunocompromised (IC) host. RECENT FINDINGS Our understanding of diarrhea in hospitalized IC patients has significantly evolved. However, the challenge lies in distinguishing between these patients' numerous causes of diarrhea. The incorporation of gastrointestinal (GI) multiplex polymerase chain reaction (PCR) panels has led to a paradigm shift in our approach to diarrhea. However, using these panels judiciously is of utmost importance, as their misuse can lead to over-testing, overtreatment, and increased hospital costs. We propose a stepwise diagnostic algorithm that ensures diagnostic stewardship, optimal patient care, and resource utilization. SUMMARY Diarrhea is a common complication in hospitalized IC patients and is associated with significant morbidity and rare mortality. The advent of new diagnostics, such as GI multiplex PCR panels, holds promise in facilitating the detection of recognized pathogens and may allow for improved outcomes using pathogen-targeted therapy.
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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
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Di Bella S, Sanson G, Monticelli J, Zerbato V, Principe L, Giuffrè M, Pipitone G, Luzzati R. Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options. Clin Microbiol Rev 2024; 37:e0013523. [PMID: 38421181 DOI: 10.1128/cmr.00135-23] [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] [Indexed: 03/02/2024] Open
Abstract
SUMMARYClostridioides difficile infection (CDI) is one of the major issues in nosocomial infections. This bacterium is constantly evolving and poses complex challenges for clinicians, often encountered in real-life scenarios. In the face of CDI, we are increasingly equipped with new therapeutic strategies, such as monoclonal antibodies and live biotherapeutic products, which need to be thoroughly understood to fully harness their benefits. Moreover, interesting options are currently under study for the future, including bacteriophages, vaccines, and antibiotic inhibitors. Surveillance and prevention strategies continue to play a pivotal role in limiting the spread of the infection. In this review, we aim to provide the reader with a comprehensive overview of epidemiological aspects, predisposing factors, clinical manifestations, diagnostic tools, and current and future prophylactic and therapeutic options for C. difficile infection.
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Affiliation(s)
- Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Gianfranco Sanson
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Jacopo Monticelli
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), Trieste, Italy
| | - Verena Zerbato
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), Trieste, Italy
| | - Luigi Principe
- Microbiology and Virology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Mauro Giuffrè
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
- Department of Internal Medicine (Digestive Diseases), Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Giuseppe Pipitone
- Infectious Diseases Unit, ARNAS Civico-Di Cristina Hospital, Palermo, Italy
| | - Roberto Luzzati
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
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Polpichai N, Saowapa S, Jaroenlapnopparat A, Wattanachayakul P, Danpanichkul P, Tanariyakul M, Trongtorsak A. Impact of colon cancer on outcomes in hospitalized patients with Clostridioides difficile infection: a national inpatient analysis. Proc AMIA Symp 2024; 37:544-550. [PMID: 38910791 PMCID: PMC11188809 DOI: 10.1080/08998280.2024.2352817] [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: 03/28/2024] [Accepted: 04/26/2024] [Indexed: 06/25/2024] Open
Abstract
Background and aim Clostridioides difficile infection (CDI) burdens hospitalized patients, particularly those with comorbidities. Colon cancer may worsen CDI severity and outcomes. We aimed to assess CDI outcomes in hospitalized colon cancer patients. Methods A retrospective analysis of 2016 to 2020 National Inpatient Survey data identified adults with CDI, categorized by the presence of colon cancer. Hospitalization characteristics, comorbidities, and outcomes were compared between groups. Primary outcomes included in-hospital mortality, length of stay, and total hospital charges. The secondary outcomes were CDI complications. Multivariate logistic regression analysis was performed, with P values ≤0.05 indicating statistical significance. Results Among 1,436,860 CDI patients, 14,085 had colon cancer. Patients with colon cancer had a longer length of stay (10.77 vs 9.98 days; P < 0.001). After adjustment for confounders, colon cancer patients exhibited higher odds of acute peritonitis (adjusted odds ratio [aOR] 2.37; P = 0.009), bowel perforation (aOR 5.49; P < 0.001), paralytic ileus (aOR 2.12; P = 0.003), and colectomy (aOR 36.99; P < 0.001), but lower risks of mortality, sepsis, septic shock, acute kidney injury, cardiac arrest, and mechanical ventilation (all P < 0.001). Conclusion Colon cancer significantly impacts CDI outcomes in hospitalized patients, highlighting the need for improved management strategies to reduce morbidity and mortality.
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Affiliation(s)
- Natchaya Polpichai
- Department of Internal Medicine, Weiss Memorial Hospital, Chicago, Illinois, USA
| | - Sakditad Saowapa
- Department of Internal Medicine, Texas Tech University Health Science Center, Lubbock, Texas, USA
| | - Aunchalee Jaroenlapnopparat
- Department of Internal Medicine, Mount Auburn Hospital/Harvard Medical School, Cambridge, Massachusetts, USA
| | | | - Pojsakorn Danpanichkul
- Immunology Unit, Department of Microbiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Manasawee Tanariyakul
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Angkawipa Trongtorsak
- Department of Cardiovascular Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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Piekarska A, Sadowska-Klasa A, Mensah-Glanowska P, Sobczyk-Kruszelnicka M, Drozd-Sokołowska J, Waszczuk-Gajda A, Kujawska J, Wilk M, Tomaszewska A, Zaucha JM, Giebel S, Gil L. Effective treatment of Clostridioides difficile infection improves survival and affects graft-versus-host disease: a multicenter study by the Polish Adult Leukemia Group. Sci Rep 2024; 14:5947. [PMID: 38467719 PMCID: PMC10928209 DOI: 10.1038/s41598-024-56336-3] [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: 09/28/2023] [Accepted: 03/05/2024] [Indexed: 03/13/2024] Open
Abstract
Clostridioides difficile infection (CDI) is the most common cause of infectious diarrhea after allogeneic hematopoietic cell transplantation (allo-HCT). The impact of CDI and its treatment on allo-HCT outcomes and graft-versus-host disease (GVHD), including gastrointestinal GVHD (GI-GVHD) is not well established. This multicenter study assessed real-life data on the first-line treatment of CDI and its impact on allo-HCT outcomes. Retrospective and prospective data of patients with CDI after allo-HCT were assessed. We noted statistically significant increase in the incidence of acute GVHD and acute GI-GVHD after CDI (P = 0.005 and P = 0.016, respectively). The first-line treatment for CDI included metronidazole in 34 patients, vancomycin in 64, and combination therapy in 10. Treatment failure was more common with metronidazole than vancomycin (38.2% vs. 6.2%; P < 0.001). The need to administer second-line treatment was associated with the occurrence or exacerbation of GVHD (P < 0.05) and GI-GVHD (P < 0.001) and reduced overall survival (P < 0.05). In the multivariate analysis, the risk of death was associated with acute GVHD presence before CDI (hazard ratio [HR], 3.19; P = 0.009) and the need to switch to second-line treatment (HR, 4.83; P < 0.001). The efficacy of the initial CDI treatment affects survival and occurrence of immune-mediated GI-GVHD after allo-HCT. Therefore, agents with higher efficacy than metronidazole (vancomycin or fidaxomicin) should be administered as the first-line treatment.
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Affiliation(s)
- Agnieszka Piekarska
- Department of Hematology and Transplantology, Medical University of Gdańsk and University Clinical Center, ul. Smoluchowskiego 17, 80-214, Gdańsk, Poland.
| | - Alicja Sadowska-Klasa
- Department of Hematology and Transplantology, Medical University of Gdańsk and University Clinical Center, ul. Smoluchowskiego 17, 80-214, Gdańsk, Poland
| | - Patrycja Mensah-Glanowska
- Department of Hematology, Jagiellonian University Collegium Medicum, University Hospital in Cracow, Cracow, Poland
| | - Małgorzata Sobczyk-Kruszelnicka
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Anna Waszczuk-Gajda
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Kujawska
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | - Mateusz Wilk
- Department of Hematology, University Hospital in Cracow, Cracow, Poland
| | - Agnieszka Tomaszewska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Jan M Zaucha
- Department of Hematology and Transplantology, Medical University of Gdańsk and University Clinical Center, ul. Smoluchowskiego 17, 80-214, Gdańsk, Poland
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
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Alamri A, Bin Abbas A, Al Hassan E, Almogbel Y. Development of a Prediction Model to Identify the Risk of Clostridioides difficile Infection in Hospitalized Patients Receiving at Least One Dose of Antibiotics. PHARMACY 2024; 12:37. [PMID: 38392945 PMCID: PMC10892393 DOI: 10.3390/pharmacy12010037] [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: 09/26/2023] [Revised: 01/30/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVE This study's objective was to develop a risk-prediction model to identify hospitalized patients at risk of Clostridioides difficile infection (CDI) who had received at least one dose of systemic antibiotics in a large tertiary hospital. PATIENTS AND METHODS This was a retrospective case-control study that included patients hospitalized for more than 2 days who received antibiotic therapy during hospitalization. The study included two groups: patients diagnosed with hospital CDI and controls without hospital CDI. Cases were matched 1:3 with assigned controls by age and sex. Descriptive statistics were used to identify the study population by comparing cases with controls. Continuous variables were stated as the means and standard deviations. A multivariate analysis was built to identify the significantly associated covariates between cases and controls for CDI. RESULTS A total of 364 patients were included and distributed between the two groups. The control group included 273 patients, and the case group included 91 patients. The risk factors for CDI were investigated, with only significant risks identified and included in the risk assessment model: age older than 70 years (p = 0.034), chronic kidney disease (p = 0.043), solid organ transplantation (p = 0.021), and lymphoma or leukemia (p = 0.019). A risk score of ≥2 showed the best sensitivity, specificity, and accuracy of 78.02%, 45.42%, and 78.02, respectively, with an area under the curve of 0.6172. CONCLUSION We identified four associated risk factors in the risk-prediction model. The tool showed good discrimination that might help predict, identify, and evaluate hospitalized patients at risk of developing CDI.
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Affiliation(s)
- Abdulrahman Alamri
- Pharmaceutical Care Services, Ministry of the National Guard Health Affairs, Riyadh 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 11481, Saudi Arabia
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia
| | - AlHanoof Bin Abbas
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraidah 51452, Saudi Arabia; (A.B.A.); (Y.A.)
| | - Ekram Al Hassan
- Department of Pathology and Laboratory Medicine, Ministry of the National Guard Health Affairs, Riyadh 11426, Saudi Arabia;
| | - Yasser Almogbel
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraidah 51452, Saudi Arabia; (A.B.A.); (Y.A.)
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Rees MJ, Rivalland A, Tan S, Xie M, Yong MK, Ritchie D. Non-viral pathogens of infectious diarrhoea post-allogeneic stem cell transplantation are associated with graft-versus-host disease. Ann Hematol 2024; 103:593-602. [PMID: 37926752 DOI: 10.1007/s00277-023-05526-6] [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: 07/04/2023] [Accepted: 10/26/2023] [Indexed: 11/07/2023]
Abstract
Infectious diarrhoea is common post-allogeneic haematopoietic stem-cell transplantation (alloHSCT). While the epidemiology of Clostridioides difficile infection (CDI) post-alloHSCT has been described, the impact of other diarrhoeal pathogens is uncertain. We reviewed all alloHSCT between 2017 and 2022 at a single large transplant centre; 374 patients were identified and included. The 1-year incidence of infectious diarrhoea was 23%, divided into viral (13/374, 3%), CDI (65/374, 17%) and other bacterial infections (16/374, 4%). There was a significant association between infectious diarrhoea within 1 year post-transplant and the occurrence of severe acute lower gastrointestinal graft-versus-host disease (GVHD, OR = 4.64, 95% CI 2.57-8.38, p < 0.001) and inferior GVHD-free, relapse-free survival on analysis adjusted for age, donor type, stem cell source and T-cell depletion (aHR = 1.64, 95% CI = 1.18-2.27, p = 0.003). When the classes of infectious diarrhoea were compared to no infection, bacterial (OR = 6.38, 95% CI 1.90-21.40, p = 0.003), CDI (OR = 3.80, 95% CI 1.91-7.53, p < 0.001) and multiple infections (OR = 11.16, 95% CI 2.84-43.92, p < 0.001) were all independently associated with a higher risk of severe GI GVHD. Conversely, viral infections were not (OR = 2.98, 95% CI 0.57-15.43, p = 0.20). Non-viral infectious diarrhoea is significantly associated with the development of GVHD. Research to examine whether the prevention of infectious diarrhoea via infection control measures or modulation of the microbiome reduces the incidence of GVHD is needed.
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Affiliation(s)
- Matthew J Rees
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, 305 Grattan St, Melbourne, VIC, 3000, Australia.
| | - Alexandra Rivalland
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, 305 Grattan St, Melbourne, VIC, 3000, Australia
| | - Sarah Tan
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, 305 Grattan St, Melbourne, VIC, 3000, Australia
| | - Mingdi Xie
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, 305 Grattan St, Melbourne, VIC, 3000, Australia
| | - Michelle K Yong
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Victorian Infectious Diseases Service, Melbourne Health, Melbourne, Australia
- Sir Peter MacCallum, Department of Oncology, University of Melbourne, Melbourne, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Melbourne, Australia
| | - David Ritchie
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, 305 Grattan St, Melbourne, VIC, 3000, Australia
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Ragozzino S, Mueller NJ, Neofytos D, Passweg J, Müller A, Medinger M, Van Delden C, Masouridi-Levrat S, Chalandon Y, Tschudin-Sutter S, Khanna N. Epidemiology, outcomes and risk factors for recurrence of Clostridioides difficile infections following allogeneic hematopoietic cell transplantation: a longitudinal retrospective multicenter study. Bone Marrow Transplant 2024; 59:278-281. [PMID: 38036657 PMCID: PMC10849940 DOI: 10.1038/s41409-023-02157-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/07/2023] [Accepted: 11/16/2023] [Indexed: 12/02/2023]
Affiliation(s)
- Silvio Ragozzino
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Dionysios Neofytos
- Transplant Infectious Diseases Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Jakob Passweg
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Antonia Müller
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
- Department of Transfusion Medicine and Cell Therapy, Medical University of Vienna, Vienna, Austria
| | - Michael Medinger
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Christian Van Delden
- Transplant Infectious Diseases Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Stavroula Masouridi-Levrat
- Division of Hematology, University Hospitals Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Yves Chalandon
- Division of Hematology, University Hospitals Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sarah Tschudin-Sutter
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
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Prayag¹ PS, Patwardhan SA, Ajapuje PS, Melinkeri S, Gadhikar H, Palnitkar S, Simbasivam R, Joshi RS, Baheti A, Sheth US, Prayag AP. Fecal Microbiota Transplantation for Clostridium difficile-associated Diarrhea in Hematopoietic Stem Cell Transplant Recipients: A Single-center Experience from a Tertiary Center in India. Indian J Crit Care Med 2024; 28:106-110. [PMID: 38323255 PMCID: PMC10839937 DOI: 10.5005/jp-journals-10071-24607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/17/2023] [Indexed: 02/08/2024] Open
Abstract
Objectives Fecal microbiota transplantation (FMT) is an emerging option for recurrent or refractory Clostridium difficile-associated diarrhea (CDAD). We describe a single-center experience of FMT in hematopoietic stem cell transplant (HSCT) recipients with CDAD in India. Methods A prospective observational study of HSCT recipients with CDAD who received FMT in our center. Results A total of 13 patients were included. All the patients were allogenic HSCT recipients; FMT was performed in seven patients due to refractory CDAD, in five patients due to the presence of both CDAD and graft vs host disease (GVHD), and in 1 patient due to recurrent CDAD. The approach to FMT was colonoscopic in 10 (77%) patients. Only one patient reported bacteremia and one patient had candidemia, both of which were unrelated to FMT. Of the 10 patients who had complete resolution of CDAD, only one patient presented with a recurrence of CDAD within 8 weeks post-FMT. Conclusion This is the first study from India using FMT as a therapeutic modality for CDAD in the setting of HSCT. Here we demonstrate that FMT in India is an effective option, especially when patients have refractory CDAD, recurrent CDAD, or both GVHD and CDAD. Further studies should explore the efficacy and feasibility of FMT in India. How to cite this article Prayag PS, Patwardhan SA, Ajapuje PS, Melinkeri S, Gadhikar H, Palnitkar S, et al. Fecal Microbiota Transplantation for Clostridium difficile-associated Diarrhea in Hematopoietic Stem Cell Transplant Recipients: A Single-center Experience from a Tertiary Center in India. Indian J Crit Care Med 2024;28(2):106-110.
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Affiliation(s)
- Parikshit Shirish Prayag¹
- Department of Infectious Diseases, Deenanath Mangeshkar Hospital & Research Center, Pune, Maharashtra, India
| | - Sampada Ajeet Patwardhan
- Department of Microbiology, Deenanath Mangeshkar Hospital & Research Center, Pune, Maharashtra, India
| | - Preeti Shankarrao Ajapuje
- Department of Infectious Diseases, Deenanath Mangeshkar Hospital & Research Center, Pune, Maharashtra, India
| | - Sameer Melinkeri
- Department of Clinical Hematology, Deenanath Mangeshkar Hospital & Research Center, Pune, Maharashtra, India
| | - Harshal Gadhikar
- Department of Gastroenterology, Deenanath Mangeshkar Hospital & Research Center, Pune, Maharashtra, India
| | - Sachin Palnitkar
- Department of Gastroenterology, Deenanath Mangeshkar Hospital & Research Center, Pune, Maharashtra, India
| | - Ramya Simbasivam
- Department of Infectious Diseases, Deenanath Mangeshkar Hospital & Research Center, Pune, Maharashtra, India
| | - Rasika Saheel Joshi
- Department of Infectious Diseases, Deenanath Mangeshkar Hospital & Research Center, Pune, Maharashtra, India
| | - Abhijit Baheti
- Department of Clinical Hematology, Deenanath Mangeshkar Hospital & Research Center, Pune, Maharashtra, India
| | - Urmi Sitanshu Sheth
- Department of Clinical Hematology, Deenanath Mangeshkar Hospital & Research Center, Pune, Maharashtra, India
| | - Amrita Parikshit Prayag
- Department of In-house Research, Deenanath Mangeshkar Hospital & Research Center, Pune, Maharashtra, India
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Alsoubani M, Chow JK, Rodday AM, Kent D, Snydman DR. Comparative Effectiveness of Fidaxomicin vs Vancomycin in Populations With Immunocompromising Conditions for the Treatment of Clostridioides difficile Infection: A Single-Center Study. Open Forum Infect Dis 2024; 11:ofad622. [PMID: 38204563 PMCID: PMC10781433 DOI: 10.1093/ofid/ofad622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 12/05/2023] [Indexed: 01/12/2024] Open
Abstract
Background Clostridioides difficile infection (CDI) is a leading cause of morbidity in immunocompromised hosts with increased risk of complications and recurrences. In this study, we examined the clinical effectiveness of fidaxomicin vs vancomycin in treating CDI in this patient population. Methods This single-center retrospective study evaluated patients with CDI between 2011 and 2021. The primary outcome was a composite of clinical failure, relapse at 30 days, or CDI-related death. A multivariable cause-specific Cox proportional hazards model was used to test the relationship between treatment and the composite outcome, adjusting for confounders and treating death from other causes as a competing risk. Results This study analyzed 238 patients who were immunocompromised and treated for CDI with oral fidaxomicin (n = 38) or vancomycin (n = 200). There were 42 composite outcomes: 4 (10.5%) in the fidaxomicin arm and 38 (19.0%) in the vancomycin arm. After adjustment for sex, number of antecedent antibiotics, CDI severity and type of immunosuppression, fidaxomicin use significantly decreased the risk of the composite outcome as compared with vancomycin (10.5% vs 19.0%; hazard ratio, 0.28; 95% CI, .08-.93). Furthermore, fidaxomicin was associated with 70% reduction in the combined risk of 30- and 90-day relapse following adjustment (hazard ratio, 0.27; 95% CI, .08-.91). Conclusions The findings of this study suggest that the use of fidaxomicin for treatment of CDI reduces poor outcomes in patients who are immunocompromised.
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Affiliation(s)
- Majd Alsoubani
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jennifer K Chow
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Angie Mae Rodday
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - David Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, School of Medicine, Tufts University, Boston, Massachusetts, USA
| | - David R Snydman
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
- The Stuart B. Levy Center for the Integrated Management of Antimicrobial Resistance, School of Medicine, Tufts University, Boston, Massachusetts, USA
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11
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Puerta-Alcalde P, Garcia-Vidal C, Soriano A. Prevention and treatment of C. difficile in cancer patients. Curr Opin Infect Dis 2023; 36:473-480. [PMID: 37527003 DOI: 10.1097/qco.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
PURPOSE OF REVIEW We provide an update on the recent literature on Clostridioides difficile infection (CDI) in cancer patients. RECENT FINDINGS Distinguishing between colonization and infection remains challenging in cancer patients. Many patients with negative toxin analysis are still treated for CDI, and some meet criteria for severe cases. The incidence of CDI is high in cancer patients, especially those with haematological malignancies. Disruption of the gut microbiome due to antibiotic consumption, chemotherapy and radiotherapy is the primary factor contributing to CDI development. The severity of CDI in cancer patients is often unclear due to the absence of well-defined severity criteria. Certain microbiome species predominance and specific ribotypes have been associated with worse outcomes. Whole genome sequencing could be helpful for differentiating recurrence from reinfection and exploring potential nosocomial transmission. While certain new drugs such as fidaxomicin or bezlotoxumab show promise, the optimal treatment and prevention strategies for CDI in cancer patients remain uncertain. Faecal microbiota transplantation (FMT) holds potential for reducing CDI recurrence rates. SUMMARY Further studies are needed to provide robust recommendations for diagnosis, grading severity, and therapeutic management of CDI in cancer patients. Recurrences are particularly concerning due to subsequent exposition to CDI risk factors.
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Lo Porto D, Mularoni A, Castagnola E, Saffioti C. Clostridioides difficile infection in the allogeneic hematopoietic cell transplant recipient. Transpl Infect Dis 2023; 25 Suppl 1:e14159. [PMID: 37787395 DOI: 10.1111/tid.14159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/09/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023]
Abstract
Clostridioides difficile (CD) is one of the most important causes of diarrhea in hospitalized patients, in particular those who undergo an allogeneic hematopoietic cell transplant (allo-HCT) and who are more at risk of developing a CD infection (CDI) due to frequent hospitalizations, iatrogenic immunosuppression, and prolonged antibiotic cycles. CDI may represent a severe condition in allo-HCT patients, increasing the length of hospitalization, influencing the intestinal microbiome with a bidirectional association with graft-versus-host disease, and leading to unfavorable outcomes, including death. The diagnosis of CDI requires the exclusion of other probable causes of diarrhea in HCT patients and is based on highly sensitive and highly specific tests to distinguish colonization from infection. In adult patients, fidaxomicin is recommended as first-line, with oral vancomycin as an alternative agent. Bezlotoxumab may be used to reduce the risk of recurrence. In pediatric patients, vancomycin and metronidazole are still suggested as first-line therapy, but fidaxomicin will probably become standard in pediatrics in the near future. Because of insufficient safety data, fecal microbiota transplantation is not routinely recommended in HCT in spite of promising results for the management of recurrences in other populations.
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Affiliation(s)
- Davide Lo Porto
- Unit of Infectious Diseases, IRCCS-ISMETT Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Alessandra Mularoni
- Unit of Infectious Diseases, IRCCS-ISMETT Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Elio Castagnola
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Carolina Saffioti
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Gjini E, Madec S. Towards a mathematical understanding of invasion resistance in multispecies communities. ROYAL SOCIETY OPEN SCIENCE 2023; 10:231034. [PMID: 38026034 PMCID: PMC10646464 DOI: 10.1098/rsos.231034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023]
Abstract
Multispecies community composition and dynamics are key to health and disease across biological systems, a prominent example being microbial ecosystems. Explaining the forces that govern diversity and resilience in the microbial consortia making up our body's defences remains a challenge. In this, theoretical models are crucial, to bridge the gap between species dynamics and underlying mechanisms and to develop analytic insight. Here we propose a replicator equation framework to model multispecies dynamics where an explicit notion of invasion resistance of a system emerges and can be studied explicitly. For illustration, we derive the conceptual link between such replicator equation and N microbial species' growth and interaction traits, stemming from micro-scale environmental modification. Within this replicator framework, mean invasion fitness arises, evolves dynamically, and may undergo critical predictable shifts with global environmental changes. This mathematical approach clarifies the key role of this resident system trait for invader success, and highlights interaction principles among N species that optimize their collective resistance to invasion. We propose this model based on the replicator equation as a powerful new avenue to study, test and validate mechanisms of invasion resistance and colonization in multispecies microbial ecosystems and beyond.
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Affiliation(s)
- Erida Gjini
- Center for Computational and Stochastic Mathematics, Instituto Superior Tecnico, Lisbon, Portugal
| | - Sten Madec
- Laboratory of Mathematics, University of Tours, Tours, France
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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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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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Van Galen J, Maldonado S, Grose K, Bagley F, Olivier R, Van Hoose J, Keng M, Volodin L. Minimizing the risk of Clostridioides difficile infection as an early complication of autologous stem cell transplantation. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e158. [PMID: 37771742 PMCID: PMC10523541 DOI: 10.1017/ash.2023.424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/07/2023] [Accepted: 07/09/2023] [Indexed: 09/30/2023]
Abstract
This quality improvement project aimed to reduce institutional incidence of Clostridioides difficile infection (CDI) following autologous stem cell transplantation. CDI incidence per transplant was .17 in a baseline period and .09 following the implementation of postdischarge ultraviolet room cleaning (χ2 = 2.11, p = .15).
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Affiliation(s)
- Joseph Van Galen
- Internal Medicine Residency Program, University of Virginia, Charlottesville, VA, USA
| | - Samuel Maldonado
- Internal Medicine Residency Program, University of Virginia, Charlottesville, VA, USA
| | - Kyle Grose
- Pharmacy Services, University of Kansas Health System, Kansas City, KS, USA
| | - Francis Bagley
- Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
| | - Rachele Olivier
- Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
| | - Jenna Van Hoose
- Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
| | - Michael Keng
- Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
| | - Leonid Volodin
- Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
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Kulecka M, Zeber-Lubecka N, Bałabas A, Czarnowski P, Bagińska K, Głowienka M, Kluska A, Piątkowska M, Dąbrowska M, Waker E, Mikula M, Ostrowski J. Diarrheal-associated gut dysbiosis in cancer and inflammatory bowel disease patients is exacerbated by Clostridioides difficile infection. Front Cell Infect Microbiol 2023; 13:1190910. [PMID: 37577378 PMCID: PMC10413277 DOI: 10.3389/fcimb.2023.1190910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/03/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction Low diversity gut dysbiosis can take different forms depending on the disease context. In this study, we used shotgun metagenomic sequencing and gas chromatography-mass spectrometry (GC-MS) to compared the metagenomic and metabolomic profiles of Clostridioides (Clostridium) difficile diarrheal cancer and inflammatory bowel disease (IBD) patients and defined the additive effect of C. difficile infection (CDI) on intestinal dysbiosis. Results The study cohort consisted of 138 case-mix cancer patients, 43 IBD patients, and 45 healthy control individuals. Thirty-three patients were also infected with C. difficile. In the control group, three well-known enterotypes were identified, while the other groups presented with an additional Escherichia-driven enterotype. Bacterial diversity was significantly lower in all groups than in healthy controls, while the highest level of bacterial species richness was observed in cancer patients. Fifty-six bacterial species had abundance levels that differentiated diarrheal patient groups from the control group. Of these species, 52 and 4 (Bacteroides fragilis, Escherichia coli, Klebsiella pneumoniae, and Ruminococcus gnavus) were under-represented and over-represented, respectively, in all diarrheal patient groups. The relative abundances of propionate and butyrate were significantly lower in fecal samples from IBD and CDI patients than in control samples. Isobutyrate, propanate, and butyrate concentrations were lower in cancer, IBD, and CDI samples, respectively. Glycine and valine amino acids were over- represented in diarrheal patients. Conclusion Our data indicate that different external and internal factors drive comparable profiles of low diversity dysbiosis. While diarrheal-related low diversity dysbiosis may be a consequence of systemic cancer therapy, a similar phenotype is observed in cases of moderate to severe IBD, and in both cases, dysbiosis is exacerbated by incidence of CDI.
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Affiliation(s)
- Maria Kulecka
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Natalia Zeber-Lubecka
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Aneta Bałabas
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Paweł Czarnowski
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
- Department of Biochemistry, Radioimmunology and Experimental Medicine, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Katarzyna Bagińska
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Maria Głowienka
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Anna Kluska
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Magdalena Piątkowska
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Michalina Dąbrowska
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Edyta Waker
- Department of Clinical Microbiology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Michał Mikula
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Jerzy Ostrowski
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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18
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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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Ramanathan M, Kim S, He N, Chen M, Hematti P, Abid MB, Rotz SJ, Williams KM, Lazarus HM, Wirk B, Yin DE, Kanakry CG, Perales MA, Chemaly RF, Dandoy CE, Riches M, Ustun C. The incidence and impact of clostridioides difficile infection on transplant outcomes in acute leukemia and MDS after allogeneic hematopoietic cell transplant-a CIBMTR study. Bone Marrow Transplant 2023; 58:360-366. [PMID: 36543999 PMCID: PMC10079570 DOI: 10.1038/s41409-022-01896-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/28/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
Clostridioides difficile infection (CDI) is common after allogeneic hematopoietic cell transplantation (alloHCT). The determination of incidence, risk factors, and impact of CDI on alloHCT outcomes is an unmet need. The study examines all patients aged 2 years and older who received first alloHCT for acute myeloid leukemia (AML), acute lymphocytic leukemia (ALL), or myelodysplastic syndrome (MDS) between 2013 and 2018 at US centers and reported to the Center for International Blood and Marrow Transplant Research (CIBMTR) data registry. In total, 826 patients with CDI and 6723 controls from 127 centers were analyzed. The cumulative incidence of CDI by day 100 was 18.7% (99% CI: 15-22.7%) and 10.2% (99% CI: 9.2-11.1%) in pediatric and adult patients, respectively, with a median time to diagnosis at day +13. CDI was associated with inferior overall survival (OS) (p = 0.0018) and a 2.58-fold [99% CI: 1.43-4.66; p < 0.001] increase in infection-related mortality (IRM). There was a significant overlap in the onset of acute graft versus host disease (aGVHD) and CDI. IRM increased to >4 fold when CDI + aGVHD was considered. Despite advances in the management of CDI, increased IRM and decreased OS still results from CDI.
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Affiliation(s)
- Muthalagu Ramanathan
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA.
| | - Soyoung Kim
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Naya He
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Min Chen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin, Madison, WI, USA
| | - Muhammad Bilal Abid
- Divisions of Hematology/Oncology & Infectious Diseases, BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | | | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, PA, USA
| | - Dwight E Yin
- Divisions of Infectious Diseases and Clinical Pharmacology, Department of Pediatrics, Children's Mercy Kansas City and University of Missouri at Kansas City, Kansas City, MO, USA
| | - Christopher G Kanakry
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | | | - Christopher E Dandoy
- Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Marcie Riches
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Celalettin Ustun
- Division of Hematology/Oncology/Cell Therapy, Rush University, Chicago, IL, USA
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20
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Alrugaib T, Alsultan A, Elbashir E, Albdah B, Alharbi M, Essa MF. Antimicrobial prophylaxis and the rate of blood stream infections and Clostridioides difficile in pediatric stem cell transplantation: A single-center retrospective study. Pediatr Transplant 2023; 27:e14375. [PMID: 35946349 DOI: 10.1111/petr.14375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 07/07/2022] [Accepted: 07/28/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The use of prophylactic antibiotics in the pre-engraftment period to minimize the risk of bacteremia is debatable given concerns of Clostridioides difficile (C. diff), antibiotics resistance, and disruption of gut microbiota. METHODS We retrospectively reviewed the rate and characteristics of bacteremia and C. diff infections within the first 100 days post-HSCT in all pediatric patients who received routine antibacterial prophylaxis during HSCT from 2015 to 2018. C. diff infection was defined by the presence of three or more unformed stools in 24 h and positive stool test for C. diff or its toxins. RESULTS One hundred and thirty-five (100 allogeneic and 35 autologous) transplants in 123 patients were eligible for analysis. Median age at transplant was 7.1 (range 0.2-13.7), 67 (55%) were women, and diagnosis was malignant condition in 68 patients. Median time to neutrophil engraftment was 18 days (13-23). Cefepime or piperacillin-tazobactam prophylaxis was used in 105 (78%) and 28 (21%) of patients, respectively. Only five (3%) patients had bacteremia during the pre-engraftment period, and 13 (11%) patients developed bacteremia postengraftment. Septic shock was present in only one patient pre-engraftment and was due to gram-negative bacteria. All patients who developed bacteremia received MAC. Thirteen patients (10%) of patients fulfilled C. diff infection definition. There was no mortality related to bacterial infections among our patients. CONCLUSIONS The use of antibiotic prophylaxis was associated with low rate of bacteremia in the pre-engraftment period and a 10% risk of C. diff infections. More studies are needed to better evaluate the efficacy of antibiotic prophylaxis in HSCT patients.
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Affiliation(s)
- Trad Alrugaib
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | | | - Enas Elbashir
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Bayan Albdah
- King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Musaed Alharbi
- King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Pediatrics, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed F Essa
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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21
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Infectious complications after second allogeneic hematopoietic cell transplant in adult patients with hematological malignancies. Bone Marrow Transplant 2022; 57:1820-1826. [PMID: 36151368 PMCID: PMC9510537 DOI: 10.1038/s41409-022-01827-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/12/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022]
Abstract
We conducted a retrospective review of the infectious complications and outcomes over a 2-year follow-up period of adult patients who received a second allogeneic hematopoietic cell transplant (2nd allo-HCT) during a five-year period at two cancer centers in Michigan. Sixty patients, of whom 44 (73%) had acute leukemia or myelodysplastic syndrome, were studied. The majority (n = 37,62%) received a 2nd allo-HCT because of relapsed leukemia. Infection episodes after the 2nd allo-HCT totaled 112. Bacteria were identified in 76 episodes, the majority of which occurred pre-engraftment. The most common infecting organisms were Enterococcus species and Clostridioides difficile. Viral infections, predominantly cytomegalovirus, accounted for 59 infection episodes and occurred mostly in pre-engraftment and early post-engraftment periods. There were 16 proven/probable fungal infections, of which 9 were invasive aspergillosis or candidiasis. Mortality was 45% (n = 27) at one year and 65% (n = 39) at 2 years after transplant, and 16 deaths (41%) were due to infection. Of those 16 infection deaths, 8 were bacterial, 4 fungal, 2 both bacterial and fungal, and 2 viral. Failure to engraft neutrophils or platelets was significantly associated with decreased survival, p < 0.0001 and p < 0.001, respectively. Infections are common after a 2nd allo-HCT and are associated with a high mortality rate.
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22
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Alonso CD, Maron G, Kamboj M, Carpenter PA, Gurunathan A, Mullane KM, Dubberke ER. American Society for Transplantation and Cellular Therapy Series: #5-Management of Clostridioides difficile Infection in Hematopoietic Cell Transplant Recipients. Transplant Cell Ther 2022; 28:225-232. [PMID: 35202891 DOI: 10.1016/j.jtct.2022.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 12/17/2022]
Abstract
The Practice Guidelines Committee of the American Society for Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to update its 2009 compendium-style infectious disease guidelines for hematopoietic cell transplantation (HCT). A completely new approach was taken with the goal of better serving clinical providers by publishing each standalone topic in the infectious disease series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious disease and HCT content experts developed and then answered FAQs and finalized topics with harmonized recommendations that were made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. This fifth guideline in the series focuses on Clostridioides difficile infection with FAQs that address the prevalence, incidence, clinical features, colonization versus infection, clinical complications, diagnostic considerations, pharmacological therapies for episodic or recurrent infection, and the roles of prophylactic antibiotics, probiotics, and fecal microbiota transplantation.
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Affiliation(s)
- Carolyn D Alonso
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Mini Kamboj
- Division of Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Kathleen M Mullane
- Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, Illinois
| | - Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri
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23
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Pianko MJ, Golob JL. Host-microbe interactions and outcomes in multiple myeloma and hematopoietic stem cell transplantation. Cancer Metastasis Rev 2022; 41:367-382. [PMID: 35488106 DOI: 10.1007/s10555-022-10033-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/16/2022] [Indexed: 12/12/2022]
Abstract
Microbiota are essential to normal immune development and there is growing recognition of its importance to human health and disease and deepening understanding of the complexity of host-microbe interactions in the human gut and other tissues. Commensal microbes not only can influence host immunity locally through impacts of bioactive microbial metabolites and direct interactions with epithelial cells and innate immune receptors but also can exert systemic immunomodulatory effects via impacts on host immune cells capable of trafficking beyond the gut. Emerging data suggest microbiota influence the development of multiple myeloma (MM), a malignancy of the immune system derived from immunoglobulin-producing bone marrow plasma cells, through the promotion of inflammation. Superior treatment outcomes for MM correlate with a higher abundance of commensal microbiota capable of influencing inflammatory responses through the production of butyrate. In patients with hematologic malignancies, higher levels of diversity of the gut microbiota correlate with superior outcomes after hematopoietic stem cell transplantation. Correlative data support the impact of commensal microbiota on survival, risk of infection, disease relapse, and graft-versus-host disease (GVHD) after transplant. In this review, we will discuss the current understanding of the role of host-microbe interactions and the inflammatory tumor microenvironment of multiple myeloma, discuss data describing the key role of microbiota in hematopoietic stem cell transplantation for treatment of hematologic malignancies, and highlight several possible concepts for interventions directed at the gut microbiota to influence treatment outcomes.
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Affiliation(s)
- Matthew J Pianko
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA.
| | - Jonathan L Golob
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,Department of Microbiology & Immunology, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA
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24
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Brevi A, Cogrossi LL, Lorenzoni M, Mattorre B, Bellone M. The Insider: Impact of the Gut Microbiota on Cancer Immunity and Response to Therapies in Multiple Myeloma. Front Immunol 2022; 13:845422. [PMID: 35371048 PMCID: PMC8968065 DOI: 10.3389/fimmu.2022.845422] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/25/2022] [Indexed: 11/13/2022] Open
Abstract
The human microbiota is a unique set of microorganisms colonizing the human body and evolving within it from the very beginning. Acting as an insider, the microbiota provides nutrients, and mutualistically interacts with the host’s immune system, thus contributing to the generation of barriers against pathogens. While a strong link has been documented between intestinal dysbiosis (i.e., disruption to the microbiota homeostasis) and diseases, the mechanisms by which commensal bacteria impact a wide spectrum of mucosal and extramucosal human disorders have only partially been deciphered. This is particularly puzzling for multiple myeloma (MM), a treatable but incurable neoplasia of plasma cells that accumulate in the bone marrow and lead to end-organ damage. Here we revise the most recent literature on data from both the bench and the bedside that show how the gut microbiota modulates cancer immunity, potentially impacting the progression of asymptomatic monoclonal gammopathy of undetermined significance (MGUS) and smoldering MM (SMM) to full blown MM. We also explore the effect of the gut microbiome on hematopoietic stem cell transplantation, chemotherapy, immunomodulating therapy and cancer immunotherapy in MM patients. Additionally, we identify the most cogent area of investigation that have the highest chance to delineate microbiota-related and pathobiology-based parameters for patient risk stratification. Lastly, we highlight microbiota-modulating strategies (i.e., diet, prebiotics, probiotics, fecal microbiota transplantation and postbiotics) that may reduce treatment-related toxicity in patients affected by MM as well as the rates of undertreatment of SMM patients.
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Affiliation(s)
- Arianna Brevi
- Cellular Immunology Unit, Department of Immunology, Transplantation and Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
| | - Laura Lucia Cogrossi
- Cellular Immunology Unit, Department of Immunology, Transplantation and Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Marco Lorenzoni
- Cellular Immunology Unit, Department of Immunology, Transplantation and Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
| | - Benedetta Mattorre
- Cellular Immunology Unit, Department of Immunology, Transplantation and Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
| | - Matteo Bellone
- Cellular Immunology Unit, Department of Immunology, Transplantation and Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
- *Correspondence: Matteo Bellone,
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25
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Luo Y, Zhang S, Shang H, Cui W, Wang Q, Zhu B. Prevalence of Clostridium difficile Infection in the Hematopoietic Transplantation Setting: Update of Systematic Review and Meta-Analysis. Front Cell Infect Microbiol 2022; 12:801475. [PMID: 35265530 PMCID: PMC8900492 DOI: 10.3389/fcimb.2022.801475] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/17/2022] [Indexed: 11/30/2022] Open
Abstract
Hematopoietic stem cell transplant (HSCT) recipients are vulnerable to Clostridium difficile infection (CDI) due to risk factors such as immunosuppression, antimicrobial use, and frequent hospitalization. We systematically searched PubMed and Embase to screen relevant studies from April 2014 to November 2021. A meta-analysis was performed to identify the association between CDI and hematopoietic transplantation based on the standard mean difference and 95% confidence intervals (CIs). Among the 431 retrieved citations, we obtained 43 eligible articles, which included 15,911 HSCT patients at risk. The overall estimated prevalence of CDI was 13.2%. The prevalence of CDI among the 10,685 allogeneic transplantation patients (15.3%) was significantly higher than that among the 3,840 autologous HSCT recipients (9.2%). Different incidence rates of CDI diagnosis over the last 7 years were found worldwide, of which North America (14.1%) was significantly higher than Europe (10.7%) but not significantly different from the prevalence among Asia (11.6%). Notably, we found that the estimated prevalence of CDI diagnosed by polymerase chain reaction (PCR) (17.7%) was significantly higher than that diagnosed by enzyme immunoassay (11.5%), indicating a significant discrepancy in the incidence rate of CDI owing to differences in the sensibility and specificity of the detection methods. Recurrence of CDI was found in approximately 15% of the initial patients with CDI. Furthermore, 20.3% of CDI cases were severe. CDI was found to be a common complication among HSCT recipients, displaying an evident increase in the morbidity of infection.
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Affiliation(s)
- Ying Luo
- Department of Clinical Laboratory, Zibo Central Hospital, Zibo, China
| | - Sumei Zhang
- Department of Respiratory Medicine, Zibo Central Hospital, Zibo, China
| | - Hua Shang
- Department of Gastroenterology, Zibo Central Hospital, Zibo, China
| | - Weitong Cui
- Key Laboratory of Biomedical Engineering & Technology of Shandong High School, Qilu Medical University, Zibo, China
| | - Qinglu Wang
- College of Sport and Health, Shandong Sport University, Jinan, China
- *Correspondence: Qinglu Wang,
| | - Bin Zhu
- Department of Clinical Laboratory, Zibo Central Hospital, Zibo, China
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26
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Altemeier OJ, Konrardy KT. Oral vancomycin for clostridioides difficile prophylaxis in allogenic hematopoietic cell transplant. Transpl Infect Dis 2022; 24:e13790. [PMID: 35014136 DOI: 10.1111/tid.13790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/28/2021] [Accepted: 12/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Neutropenia and antibiotic use put patients at risk for Clostridioides difficile infection (CDI) following allogenic hematopoietic cell transplant (alloHCT). CDI following alloHCT has been associated with acute graft versus host disease (aGVHD), a significant cause of morbidity and mortality in this population. We sought to evaluate if prophylactic oral vancomycin reduces the incidence of CDI in alloHCT recipients. METHODS We conducted a single center retrospective chart review to compare the effectiveness of oral vancomycin prophylaxis versus no prophylaxis in alloHCT recipients at the University of Kansas Health System. Vancomycin for CDI prophylaxis was implemented in March of 2018 at the University of Kansas Health System. Review of 100 consecutive alloHCT patients before and after this implementation was used to compare outcomes. Patients received oral vancomycin 125 mg twice daily starting on the day of inpatient admission for alloHCT and continued until discharge. The primary outcome is the incidence of CDI in patients with oral vancomycin prophylaxis compared to those who did not receive prophylaxis during hospital admission for alloHCT. The secondary endpoints include the incidence of acute grade 2-4 GVHD, and event free survival for each arm. RESULTS 11% of patients developed CDI in the control group vs. 2% of patients in the intervention group (p = 0.018). Oral vancomycin was not associated with a higher risk of acute GVHD grade 2-4 (36% vs. 38%; P = 0.77) at day 100 post-transplant. No difference was seen in Event Free Survival. CONCLUSIONS Oral vancomycin was associated with reduced CDI incidence in patients that underwent an alloHCT without negatively affecting post-transplant outcomes. The contribution of confounders cannot be excluded. This article is protected by copyright. All rights reserved.
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27
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Analysis of incidence and risk factors of the multidrug resistant gastrointestinal tract infection in children and adolescents undergoing allogeneic and autologous hematopoietic cell transplantation: a nationwide study. Ann Hematol 2021; 101:191-201. [PMID: 34674000 PMCID: PMC8720737 DOI: 10.1007/s00277-021-04681-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 09/23/2021] [Indexed: 11/18/2022]
Abstract
The aim of this multi-center study was to evaluate the incidence, clinical course, and risk factors for bacterial multidrug-resistant (MDR) gastrointestinal tract infections (GTI) among children undergoing allogeneic and autologous hematopoietic cell transplantation. A total number of 175 pediatric patients (aged 1–18 years), transplanted between January 2018 and December 2019, who were tested for bacterial colonization/infection were enrolled into this multi-center analysis. Episodes of MDR GTI occurred in 77/175 (44%) patients. In multivariate analysis for higher GTI incidence, the following factors were significant: matched-unrelated donor (MUD) transplantation, HLA mismatch, presence of graft-versus-host disease (GVHD), and gut GVHD. The most common GTI were Clostridium difficile (CDI), multidrug-resistant Enterobacteriaceae (Klebsiella pneumoniae, Escherichia coli extended-spectrum β-lactamase), and Enterococcus HLAR (high-level aminoglycoside-resistant). No MDR GTI–attributed deaths were reported. MDR GTI is a frequent complication after HCT among children, causes prolonged hospitalization, but rarely contributes to death. We identified risk factors of MDR GTI development in children, with focus on GVHD and unrelated donor and HLA mismatch. We conclude that the presence of Clostridiales plays an important anti-inflammatory homeostatic role and decreases incidence of GVHD or alleviate its course.
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28
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Obeid KM, Sapkota S, Cao Q, Richmond S, Watson AP, Karadag FK, Young JAH, Pruett T, Weisdorf DJ, Ustun C. Early Clostridioides difficile infection characterizations, risks, and outcomes in allogeneic hematopoietic stem cell and solid organ transplant recipients. Transpl Infect Dis 2021; 24:e13720. [PMID: 34455662 DOI: 10.1111/tid.13720] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/12/2021] [Accepted: 08/16/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) frequently complicates allogeneic hematopoietic stem cell (allo-HCT) and solid organ transplantation (SOT). METHODS We retrospectively analyzed risk factors and outcomes of CDI occurring within 30 days of transplant. RESULTS Between March 2010 and June 2015, 466 allo-HCT and 1454 SOT were performed. The CDI cumulative incidence (95% CI) was 10% (8-13) and 4% (3-5), following allo-HCT and SOT, respectively (p < .01), occurring at a median (range) 7.5 days (1-30) and 11 (1-30), respectively (p = .18). In multivariate analysis, fluoroquinolones use within 14 days pre-transplantation was a risk factor for CDI following allo-HCT (HR 4.06 [95% CI 1.31-12.63], p = .02), and thoracic organ(s) transplantation was a risk factor for CDI following SOT (HR 3.03 [95% CI 1.31-6.98]) for lung and 3.90 (1.58-9.63) for heart and heart/kidney transplant, p = .02. Compared with no-CDI patients, the length of stay (LOS) was prolonged in both allo-HCT (35 days [19-141] vs. 29 [13-164], p < .01) and SOT with CDI (16.5 [4-101] vs. 7 [0-159], p < .01), though not directly attributed to CDI. In allo-HCT, severe acute graft-versus-host disease (aGVHD) occurred more frequently in patients with CDI (33.3% vs. 15.8% without CDI, p = .01) and most aGVHD (87.5%) followed CDI. Non-relapse mortality or overall survival, not attributed to CDI, were also similar in both allo-HCT and SOT. CONCLUSIONS Early post-transplant CDI is frequent, associated with fluoroquinolones use in allo-HCT and the transplanted organ in SOT, and is associated with longer LOS in both the groups without difference in survival but with increased aGVHD in allo-HCT.
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Affiliation(s)
- Karam M Obeid
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Smarika Sapkota
- Division of General Internal Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Qing Cao
- Biostatistics and Informatics, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota, USA
| | - Steven Richmond
- Hospitalist Division, Department of Medicine, Hennepin Healthcare Hospital, Minneapolis, Minnesota, USA
| | - Allison P Watson
- Division of Hematology, Oncology and Transplant, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Jo-Anne H Young
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Timothy Pruett
- Division of Transplant Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplant, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplant, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,Blood and Marrow Transplant Program, Rush University, Chicago, Illinois, USA
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29
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Coccolini F, Improta M, Sartelli M, Rasa K, Sawyer R, Coimbra R, Chiarugi M, Litvin A, Hardcastle T, Forfori F, Vincent JL, Hecker A, Ten Broek R, Bonavina L, Chirica M, Boggi U, Pikoulis E, Di Saverio S, Montravers P, Augustin G, Tartaglia D, Cicuttin E, Cremonini C, Viaggi B, De Simone B, Malbrain M, Shelat VG, Fugazzola P, Ansaloni L, Isik A, Rubio I, Kamal I, Corradi F, Tarasconi A, Gitto S, Podda M, Pikoulis A, Leppaniemi A, Ceresoli M, Romeo O, Moore EE, Demetrashvili Z, Biffl WL, Wani I, Tolonen M, Duane T, Dhingra S, DeAngelis N, Tan E, Abu-Zidan F, Ordonez C, Cui Y, Labricciosa F, Perrone G, Di Marzo F, Peitzman A, Sakakushev B, Sugrue M, Boermeester M, Nunez RM, Gomes CA, Bala M, Kluger Y, Catena F. Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines. World J Emerg Surg 2021; 16:40. [PMID: 34372902 PMCID: PMC8352154 DOI: 10.1186/s13017-021-00380-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 06/18/2021] [Indexed: 02/08/2023] Open
Abstract
Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.
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Affiliation(s)
- Federico Coccolini
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Mario Improta
- grid.8982.b0000 0004 1762 5736Emergency Department, Pavia University Hospital, Pavia, Italy
| | | | - Kemal Rasa
- Department of Surgery, Anadolu Medical Center, Kocaali, Turkey
| | - Robert Sawyer
- grid.268187.20000 0001 0672 1122General Surgery Department, Western Michigan University, Kalamazoo, MI USA
| | - Raul Coimbra
- grid.488519.90000 0004 5946 0028Department of General Surgery, Riverside University Health System Medical Center, Moreno Valley, CA USA
| | - Massimo Chiarugi
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Andrey Litvin
- grid.410686.d0000 0001 1018 9204Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Timothy Hardcastle
- Emergency and Trauma Surgery, Inkosi Albert Luthuli Central Hospital, Mayville, South Africa
| | - Francesco Forfori
- grid.144189.10000 0004 1756 8209Intensive Care Unit, Pisa University Hospital, Pisa, Italy
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Departement of Intensive Care, Erasme Univ Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Andreas Hecker
- grid.411067.50000 0000 8584 9230Departementof General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Richard Ten Broek
- grid.10417.330000 0004 0444 9382General Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luigi Bonavina
- grid.416351.40000 0004 1789 6237General Surgery, San Donato Hospital, Milano, Italy
| | - Mircea Chirica
- grid.450307.5General Surgery, CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France
| | - Ugo Boggi
- grid.144189.10000 0004 1756 8209General Surgery, Pisa University Hospital, Pisa, Italy
| | - Emmanuil Pikoulis
- grid.5216.00000 0001 2155 08003rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Salomone Di Saverio
- grid.18887.3e0000000417581884General Surgery, Varese University Hospital, Varese, Italy
| | - Philippe Montravers
- grid.411119.d0000 0000 8588 831XDépartement d’Anesthésie-Réanimation, CHU Bichat Claude Bernard, Paris, France
| | - Goran Augustin
- grid.4808.40000 0001 0657 4636Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Dario Tartaglia
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Enrico Cicuttin
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Camilla Cremonini
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Bruno Viaggi
- grid.24704.350000 0004 1759 9494ICU Department, Careggi University Hospital, Firenze, Italy
| | - Belinda De Simone
- grid.418056.e0000 0004 1765 2558Department of Digestive, Metabolic and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy/Saint Germain en Laye, Saint Germain en Laye, France
| | - Manu Malbrain
- grid.8767.e0000 0001 2290 8069Faculty of Engineering, Department of Electronics and Informatics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Vishal G. Shelat
- General and Emergency Surgery, Tan Tock Seng Hospital, Kuala Lumpur, Malaysia
| | - Paola Fugazzola
- grid.8982.b0000 0004 1762 5736General and Emergency Surgery, Pavia University Hospital, Pavia, Italy
| | - Luca Ansaloni
- grid.8982.b0000 0004 1762 5736General and Emergency Surgery, Pavia University Hospital, Pavia, Italy
| | - Arda Isik
- grid.411776.20000 0004 0454 921XGeneral Surgery, School of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Ines Rubio
- grid.81821.320000 0000 8970 9163Department of General Surgery, La Paz University Hospital, Madrid, Spain
| | - Itani Kamal
- grid.38142.3c000000041936754XGeneral Surgery, VA Boston Health Care System, Boston University, Harvard Medical School, Boston, MA USA
| | - Francesco Corradi
- grid.144189.10000 0004 1756 8209Intensive Care Unit, Pisa University Hospital, Pisa, Italy
| | - Antonio Tarasconi
- grid.411482.aGeneral Surgery, Parma University Hospital, Parma, Italy
| | - Stefano Gitto
- grid.8404.80000 0004 1757 2304Gastroenterology and Transplant Unit, Firenze University Hospital, Firenze, Italy
| | - Mauro Podda
- grid.7763.50000 0004 1755 3242General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Anastasia Pikoulis
- grid.5216.00000 0001 2155 0800Medical Department, National & Kapodistrian University of Athens, Athens, Greece
| | - Ari Leppaniemi
- grid.15485.3d0000 0000 9950 5666Abdominal Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Marco Ceresoli
- grid.18887.3e0000000417581884General Surgery, Monza University Hospital, Monza, Italy
| | - Oreste Romeo
- grid.268187.20000 0001 0672 1122Department of Surgery, Western Michigan University School of Medicine, Kalamazoo, MI USA
| | - Ernest E. Moore
- grid.239638.50000 0001 0369 638XTrauma Surgery, Denver Health, Denver, CL USA
| | - Zaza Demetrashvili
- grid.412274.60000 0004 0428 8304General Surgery, Tbilisi State Medical University, Tbilisi, Georgia
| | - Walter L. Biffl
- grid.415402.60000 0004 0449 3295Emergency and Trauma Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA USA
| | - Imitiaz Wani
- General Surgery, Government Gousia Hospital, Srinagar, Kashmir India
| | - Matti Tolonen
- grid.15485.3d0000 0000 9950 5666Abdominal Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | | | - Sameer Dhingra
- National Institute of Pharmaceutical Education and Research, Hajipur (NIPER-H), Vaishali, Bihar India
| | - Nicola DeAngelis
- grid.50550.350000 0001 2175 4109General Surgery Department, Henry Mondor University Hospital, Paris, France
| | - Edward Tan
- grid.10417.330000 0004 0444 9382Emergency Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fikri Abu-Zidan
- General Surgery, UAE University Hospital, Sharjah, United Arab Emirates
| | - Carlos Ordonez
- grid.8271.c0000 0001 2295 7397Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Universidad del Valle, Cali, Colombia
| | - Yunfeng Cui
- grid.265021.20000 0000 9792 1228Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | | | - Gennaro Perrone
- grid.411482.aGeneral Surgery, Parma University Hospital, Parma, Italy
| | | | - Andrew Peitzman
- grid.21925.3d0000 0004 1936 9000General Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Michael Sugrue
- General Surgery, Letterkenny Hospital, Letterkenny, Ireland
| | - Marja Boermeester
- grid.5650.60000000404654431Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | | | - Carlos Augusto Gomes
- Department of Surgery, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital Universitário Terezinha de Jesus, Juiz de Fora, Brazil
| | - Miklosh Bala
- grid.17788.310000 0001 2221 2926General Surgery, Hadassah Hospital, Jerusalem, Israel
| | - Yoram Kluger
- General Sugery, Ramabam Medical Centre, Tel Aviv, Israel
| | - Fausto Catena
- grid.411482.aGeneral Surgery, Parma University Hospital, Parma, Italy
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Bueno F, Albert E, Giménez E, Piñana JL, Pérez A, Dolores Gómez M, Hernández-Boluda JC, Gonzalez-Barberá EM, Montoro J, Buesa J, Guerreiro M, Balaguer-Roselló A, Hernani R, Sanz J, Solano C, Navarro D. An investigation of the potential association between gastrointestinal viral and bacterial infection and development of intestinal acute graft versus host disease following allogeneic hematopoietic stem cell transplantation. J Med Virol 2021; 93:4773-4779. [PMID: 33605457 DOI: 10.1002/jmv.26892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/12/2021] [Accepted: 02/16/2021] [Indexed: 12/15/2022]
Abstract
It is uncertain whether gastrointestinal (GI) infection caused by viral and bacterial pathogens may predispose to gastrointestinal acute Graft-versus-host disease (aGvHD-GI) in allogeneic hematopoietic stem cell transplant recipients (allo-HSCT). We investigated the potential association between detection of enteropathogenic viruses or bacteria in stools and subsequent occurrence of aGvHD-GI in a cohort of 121 allo-HSCT patients. Eighty-six out of 121 patients (71%) had acute diarrhea and underwent screening for primary GI pathogens by molecular diagnostic methods. One or more GI pathogens were detected in 27 out of the 86 patients with diarrhea (31.3%). Specifically, Clostridioides difficile was found in 16 patients (18.6%), enteropathogenic viruses in 11 patients (12.7%) (Astrovirus, n = 4; Norovirus, n = 2; Sapovirus, n = 2; Adenovirus, n = 2; and Rotavirus, n = 1), and Campylobacter spp. in two patients (2.3%). Thirty patients were diagnosed with all grade aGvHD-GI by histopathology. Detection of primary GI pathogens was achieved in 12 out of 30 patients (Clostridium difficile, n = 5; enteric viruses, n = 8; Campylobacter spp., n = 1) who either subsequently developed (n = 9) or previously had (n = 3) grade I-IV IaGvHD (n = 9). Neither the detection of these microorganisms (all combined), enteric viruses, nor C. difficile was significantly associated with subsequent aGvHD-GI development in Cox models (hazard ratio [HR] = 1.11, p = .80; HR = 1.64, p = .62; HR = 0.75, p = .64, respectively). Analogous results were obtained when grade II-IV aGvHD-GI was selected as the clinical outcome. In summary, data in the current study did not support an association between GI infection and subsequent occurrence of aGvHD-GI in an unselected cohort of allo-HSCT recipients.
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Affiliation(s)
- Felipe Bueno
- Microbiology Service, University Clinical Hospital, Institute for Research INCLIVA, Valencia, Spain
| | - Eliseo Albert
- Microbiology Service, University Clinical Hospital, Institute for Research INCLIVA, Valencia, Spain
| | - Estela Giménez
- Microbiology Service, University Clinical Hospital, Institute for Research INCLIVA, Valencia, Spain
| | - José L Piñana
- Hematology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Ariadna Pérez
- Hematology Service, University Clinical Hospital, Institute for Research INCLIVA, Valencia, Spain
| | - María Dolores Gómez
- Microbiology Service, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Juan C Hernández-Boluda
- Hematology Service, University Clinical Hospital, Institute for Research INCLIVA, Valencia, Spain
- Department of Medicine, , School of Medicine, University of Valencia, Valencia, Spain
| | | | - Juan Montoro
- Hematology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Javier Buesa
- Microbiology Service, University Clinical Hospital, Institute for Research INCLIVA, Valencia, Spain
- Department of Microbiology, , School of Medicine, University of Valencia, Valencia, Spain
| | - Manuel Guerreiro
- Hematology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | | | - Rafael Hernani
- Hematology Service, University Clinical Hospital, Institute for Research INCLIVA, Valencia, Spain
| | - Jaime Sanz
- Hematology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Carlos Solano
- Hematology Service, University Clinical Hospital, Institute for Research INCLIVA, Valencia, Spain
- Department of Medicine, , School of Medicine, University of Valencia, Valencia, Spain
| | - David Navarro
- Microbiology Service, University Clinical Hospital, Institute for Research INCLIVA, Valencia, Spain
- Department of Microbiology, , School of Medicine, University of Valencia, Valencia, Spain
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31
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Horowitz JG, Gawrys GW, Lee GC, Ramirez BA, Elledge CM, Shaughnessy PJ. Early antimicrobial prophylaxis in autologous stem cell transplant recipients: Conventional versus an absolute neutrophil count-driven approach. Transpl Infect Dis 2021; 23:e13689. [PMID: 34255395 PMCID: PMC9285346 DOI: 10.1111/tid.13689] [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: 02/09/2021] [Revised: 06/23/2021] [Accepted: 06/26/2021] [Indexed: 11/30/2022]
Abstract
Background Autologous hematopoietic stem cell transplantation (HSCT) recipients are at increased risk of developing life‐threatening infections. There is discordance in published recommendations for timing of pre‐ and post‐transplant antimicrobial prophylaxis in this patient population, and these recommendations are unsubstantiated by any published comparative analyses. Methods An observational, pre‐ and post‐intervention study of consecutive autologous HSCT recipients was conducted over a 2‐year period. In the pre‐intervention cohort, antimicrobial prophylaxis was initiated on the day prior to transplant. In the post‐intervention cohort, antimicrobials were initiated once absolute neutrophil count (ANC) reached ≤500 cells/mm3. The primary outcome assessed was frequency of febrile occurrences. Secondary outcomes included total days of prophylaxis, positive blood cultures, all‐cause mortality, Clostridioides difficile infection rates, and length of stay. Results A total of 208 patients were included in the final analysis, with 105 and 103 patients in the pre‐ and post‐intervention cohorts, respectively. The majority of patients included were male. Lower rates of fever occurrences were observed in the post‐intervention cohort (83% pre‐ vs. 69% post‐intervention; p = 0.019). A significant reduction in the mean antibacterial days per patient was identified (9.7 vs. 4.6 days; p < 0.001). Other than lower rates of febrile neutropenia in the post‐intervention cohort, no differences were identified in secondary outcomes. In multivariable analyses, ANC‐driven prophylaxis was independently associated with decreased febrile events. Conclusions Delaying prophylaxis until severe neutropenia was not associated with increased febrile events or other secondary clinical outcomes evaluated. This approach is associated with a significant reduction in antimicrobial exposure.
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Affiliation(s)
- Justin G Horowitz
- Department of Pharmacy Services, Methodist Healthcare System, San Antonio, Texas, USA.,College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
| | - Gerard W Gawrys
- Department of Pharmacy Services, Methodist Healthcare System, San Antonio, Texas, USA.,College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
| | - Grace C Lee
- College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA.,Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Brittney A Ramirez
- Department of Pharmacy Services, Methodist Healthcare System, San Antonio, Texas, USA.,College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
| | - Carole M Elledge
- Adult Blood and Marrow Stem Cell Transplantation, Methodist Healthcare System, San Antonio, Texas, USA
| | - Paul J Shaughnessy
- Adult Blood and Marrow Stem Cell Transplantation, Texas Transplant Institute, San Antonio, Texas, USA
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32
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Barbar R, Hayden R, Sun Y, Tang L, Hakim H. Epidemiologic and Clinical Characteristics of Clostridioides difficile Infections in Hospitalized and Outpatient Pediatric Oncology and Hematopoietic Stem Cell Transplant Patients. Pediatr Infect Dis J 2021; 40:655-662. [PMID: 34097657 DOI: 10.1097/inf.0000000000003126] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The epidemiology and clinical course of Clostridioides difficile infection (CDI) in children, especially with cancer, are poorly defined. We aim to describe the epidemiology, clinical features and outcomes of CDI and to identify risk factors for recurrence in a pediatric oncology center. METHODS This is a retrospective cohort study of CDI in pediatric oncology and hematopoietic stem cell transplant (HSCT) patients in 2016 and 2017. CDI cases were identified by positive C. difficile test in symptomatic patients. CDI episodes were classified as incident, duplicate or recurrent and community-onset, hospital-onset or community-onset healthcare facility-associated. Data about clinical course and outcomes were abstracted. Risk factors for CDI recurrence were assessed by logistic regression. RESULTS One hundred seventy-eight patients 1 year of age and older developed 291 CDI episodes; 78% were incident and 22% recurrent. Underlying diagnoses were leukemia/lymphoma (57%) and solid/brain tumors (41%); 30% were HSCT recipients. Antibiotics, chemotherapy, antacids, steroids and laxatives were received by 96%, 82%, 70%, 47% and 15%, respectively. Half of the patients were neutropenic. Twenty-two percent of outpatients with CDI required hospitalization. Chemotherapy was delayed in 25%. There were no intensive care unit admissions nor deaths due to CDI. Exposure to H2-antagonists was identified as an independent risk factor for CDI recurrence. CONCLUSIONS Although CDI in pediatric oncology and HSCT patients was associated with chemotherapy delay and hospitalization in approximately a quarter of patients, it was not associated with morbidity or mortality because patients had no attributable intensive care unit admission nor death. H2-antagonists are independent risk factors for CDI recurrence.
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Affiliation(s)
| | | | - Yilun Sun
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Li Tang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Hana Hakim
- From the Department of Infectious Diseases
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33
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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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34
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Alonso CD, Papamichael K, Sprague R, Barrett C, Gonzales-Luna AJ, Daugherty K, Garey KW, Villafuerte-Gálvez J, Xu H, Lin Q, Wang L, Chen X, Pollock NR, Kelly CP. Humoral Immune Response to Clostridioides difficile Toxins A and B in Hospitalized Immunocompromised Patients With C difficile Infection. Open Forum Infect Dis 2021; 8:ofab286. [PMID: 34258317 PMCID: PMC8271131 DOI: 10.1093/ofid/ofab286] [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: 03/29/2021] [Accepted: 05/26/2021] [Indexed: 11/14/2022] Open
Abstract
Background The humoral immune response to Clostridioides difficile toxins in C difficile infection (CDI) is incompletely characterized in immunocompromised hosts (ICHs). Methods We conducted a prospective study of hospitalized adults with CDI, with and without immunosuppression (hematologic malignancy, active solid tumor, solid organ or stem cell transplant, inflammatory bowel disease, autoimmune disease, congenital or acquired immunodeficiency, asplenia, chronic receipt of high-dose steroids, or receipt of immunosuppressing medications within 12 months). Serum and stool antibody concentrations of immunoglobulin (Ig)M, IgG, and IgA to C difficile toxins A and B at treatment days 0, 3, and 10–14 were compared. Results Ninety-eight subjects (47 ICH; 51 non-ICH) were enrolled. Baseline serum antitoxin A and B antibody levels were similar. At day 3, ICHs demonstrated lower serum levels of antitoxin A IgG, antitoxin A IgA, and antitoxin B IgA (all P < .05). At day 10–14, lower antitoxin A IgG concentrations were observed in ICHs (ICH, 21 enzyme-linked immunosorbent assay [ELISA] units; interquartile range [IQR], 16.4–44.6) compared with non-ICH subjects (49.0 ELISA units; IQR, 21.5–103; P = .045). In stool, we observed lower concentrations of antitoxin B IgA antibodies at baseline and at day 3 for ICH subjects, with a notable difference in concentrations of antitoxin B IgA at day 3 (ICH, 6.7 ELISA units [IQR, 1.9–13.9] compared with non-ICH, 18.1 ELISA units [IQR, 4.9–31.7]; P = .003). Conclusions The ICHs with CDI demonstrated lower levels of C difficile antitoxin antibodies in serum and stool during early CDI therapy compared with non-ICHs. These data provide insight into the humoral response to CDI in ICHs.
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Affiliation(s)
- Carolyn D Alonso
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Konstantinos Papamichael
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rebecca Sprague
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Caitlin Barrett
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Kaitlyn Daugherty
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Javier Villafuerte-Gálvez
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Hua Xu
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Qianyun Lin
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lamei Wang
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,College of Animal Science and Technology, Northwest A&F University, Yangling, Shaanxi Province, China
| | - Xinhua Chen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nira R Pollock
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ciarán P Kelly
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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35
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Henig I, Yehudai-Ofir D, Zuckerman T. The clinical role of the gut microbiome and fecal microbiota transplantation in allogeneic stem cell transplantation. Haematologica 2021; 106:933-946. [PMID: 33241674 PMCID: PMC8017815 DOI: 10.3324/haematol.2020.247395] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 08/28/2020] [Indexed: 12/26/2022] Open
Abstract
Outcomes of allogeneic hematopoietic stem cell transplantation (allo- HSCT) have improved in the recent decade; however, infections and graft-versus-host disease remain two leading complications significantly contributing to early transplant-related mortality. In past years, the human intestinal microbial composition (microbiota) has been found to be associated with various disease states, including cancer, response to cancer immunotherapy and to modulate the gut innate and adaptive immune response. In the setting of allo-HSCT, the intestinal microbiota diversity and composition appear to have an impact on infection risk, mortality and overall survival. Microbial metabolites have been shown to contribute to the health and integrity of intestinal epithelial cells during inflammation, thus mitigating graft-versus-host disease in animal models. While the cause-andeffect relationship between the intestinal microbiota and transplant-associated complications has not yet been fully elucidated, the above findings have already resulted in the implementation of various interventions aiming to restore the intestinal microbiota diversity and composition. Among others, these interventions include the administration of fecal microbiota transplantation. The present review, based on published data, is intended to define the role of the latter approach in the setting of allo-HSCT.
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Affiliation(s)
- Israel Henig
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa
| | - Dana Yehudai-Ofir
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa
| | - Tsila Zuckerman
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa.
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36
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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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37
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Dutta D, Jafri F, Stuhr D, Knoll BM, Lim SH. A contemporary review of Clostridioides difficile infections in patients with haematologic diseases. J Intern Med 2021; 289:293-308. [PMID: 32910532 DOI: 10.1111/joim.13173] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/18/2020] [Indexed: 12/14/2022]
Abstract
Clostridioides (Clostridium) difficile (C. difficile) infection is one of the most common causes of increased morbidity and mortality. Approximately 500 000 C. difficile infections (CDIs) occur each year in the United States, and they result in more than 29 000 deaths. Patients with haematologic diseases are at a higher risk for this infection due to frequent hospitalization and exposure to treatment-associated risk factors. Whilst several currently available antimicrobial agents offer resolution, recurrence of infection remains a major concern. Recent advancement in deciphering C. difficile virulence mechanisms and identification of its allies in contributing to the infection has led to the development of alternative treatment strategies. Here, we will provide a contemporary discussion of how major risk factors in haematologic diseases, such as immunosuppression, chemoradiation, use of antibiotic, proton pump inhibitor and opioid, and deficiency in butyrate and antimicrobial peptides contribute to C. difficile infection. Next, we will highlight different approaches to control and mitigate this infection such as antibiotic stewardship and faecal microbiota transplantation. Finally, we will explore several emerging treatments such as use of pre- and probiotics, immunotherapy and microbiome-sparing agents.
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Affiliation(s)
- D Dutta
- From the, Division of Hematology and Oncology, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA.,Division of Hematology and Oncology, New York Medical College, Valhalla, NY, USA
| | - F Jafri
- Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - D Stuhr
- Division of Hematology and Oncology, New York Medical College, Valhalla, NY, USA.,Lake Erie College of Osteopathic Medicine, Bradenton, FL, USA
| | - B M Knoll
- Department of Medicine, New York Medical College, Valhalla, NY, USA.,Division of Infectious Diseases, New York Medical College, Valhalla, NY, USA
| | - S H Lim
- From the, Division of Hematology and Oncology, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA.,Division of Hematology and Oncology, New York Medical College, Valhalla, NY, USA
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38
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Vijayvargiya P, Lara Abad C, Esquer Garrigos Z, O'Horo JC, Walker RC, Hogan WJ, Tande AJ. D-index as a marker of bloodstream infections in patients with allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2021; 23:e13588. [PMID: 33590904 DOI: 10.1111/tid.13588] [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: 08/04/2020] [Revised: 01/31/2021] [Accepted: 02/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neutropenia is a risk factor for development of infections; however, the direct effect of neutropenia on development of bloodstream infection (BSI) is not known. D-index, which is area between the neutrophil time curve and a neutrophil count of 0.5 × 109 /L, incorporates the combined effect of severity and duration of neutropenia. We aimed to evaluate whether D-index can be used as a marker for BSI in patients with allogeneic stem cell transplantation. METHOD We conducted a retrospective cohort study of patients undergoing allogeneic stem cell transplantation between January 1, 2005, and September 30, 2015. The primary outcome measure was the development of BSI within 30 days of transplantation. RESULTS A total of 714 patients were included in the study of whom 101 developed BSI. Patients with BSI had a significantly higher median D-index value compared with patients who did not have BSI (4990 vs. 3570, P < .001). As a marker, the performance of the D-index was similar to that of the duration of profound neutropenia (P = .18) and significantly better than the total duration of neutropenia (P = .001). CONCLUSION The D-index performed better than the total duration of neutropenia as a marker for BSI in patients with allogeneic stem cell transplantation. There was no difference between D-index and, a more easily calculable indicator, duration of profound neutropenia.
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Affiliation(s)
- Prakhar Vijayvargiya
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Divison of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Cybele Lara Abad
- Department of Medicine, Section of Infectious Diseases, University of the Philippines Manila, UP-PGH, Manila, Philippines
| | - Zerelda Esquer Garrigos
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Divison of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - John C O'Horo
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Randall C Walker
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - William J Hogan
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aaron J Tande
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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39
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Elgarten CW, Li Y, Getz KD, Hemmer M, Huang YSV, Hall M, Wang T, Kitko CL, Jagasia MH, Nishihori T, Murthy HS, Hashem H, Cairo MS, Sharma A, Hashmi SK, Askar M, Beitinjaneh A, Kelly MS, Auletta JJ, Badawy SM, Mavers M, Aplenc R, MacMillan ML, Spellman SR, Arora M, Fisher BT. Broad-Spectrum Antibiotics and Risk of Graft-versus-Host Disease in Pediatric Patients Undergoing Transplantation for Acute Leukemia: Association of Carbapenem Use with the Risk of Acute Graft-versus-Host Disease. Transplant Cell Ther 2020; 27:177.e1-177.e8. [PMID: 33718896 DOI: 10.1016/j.jtct.2020.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Variation in the gastrointestinal (GI) microbiota after hematopoietic cell transplantation (HCT) has been associated with acute graft-versus-host disease (aGVHD). Because antibiotics induce dysbiosis, we examined the association of broad-spectrum antibiotics with subsequent aGVHD risk in pediatric patients undergoing HCT for acute leukemia. We performed a retrospective analysis in a dataset merged from 2 sources: (1) the Center for International Blood and Marrow Transplant Research, an observational transplantation registry, and (2) the Pediatric Health Information Services, an administrative database from freestanding children's hospitals. We captured exposure to 3 classes of antibiotics used for empiric treatment of febrile neutropenia: (1) broad-spectrum cephalosporins, (2) antipseudomonal penicillins, and (3) carbapenems. The primary outcome was grade II-IV aGVHD; secondary outcomes were grade III-IV aGVHD and lower GI GVHD. The adjusted logistic regression model (full cohort) and time-to-event analysis (subcohort) included transplantation characteristics, GVHD risk factors, and adjunctive antibiotic exposures as covariates. The full cohort included 2550 patients at 36 centers; the subcohort included 1174 patients. In adjusted models, carbapenems were associated with an increased risk of grade II-IV aGVHD in the full cohort (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.02 to 1.51) and subcohort (sub hazard ratio [HR], 1.31; 95% CI, 0.99 to 1.72), as well as with an increased risk of grade III-IV aGVHD (subHR, 1.77; 95% CI, 1.25 to 2.52). Early carbapenem exposure (before day 0) especially impacted aGVHD risk. For antipseudomonal penicillins, the associations with aGVHD were in the direction of increased risk but were not statistically significant. There was no identified association between broad-spectrum cephalosporins and aGVHD. Carbapenems, more than other broad-spectrum antibiotics, should be used judiciously in pediatric HCT recipients to minimize aGVHD risk. Further research is needed to clarify the mechanism underlying this association.
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Affiliation(s)
- Caitlin W Elgarten
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Yimei Li
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | - Kelly D Getz
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | | | - Yuan-Shung V Huang
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Tao Wang
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Carrie L Kitko
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Hemant S Murthy
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | - Mitchell S Cairo
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN
| | - Shahrukh K Hashmi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Medhat Askar
- Department of Pathology and Laboratory Medicine, Baylor University Medical Center, Dallas, TX
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami, Miami, FL
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, NC
| | - Jeffery J Auletta
- Blood and Marrow Transplant Program and Host Defense Program, Divisions of Hematology/Oncology/Bone Marrow Transplant and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH
| | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Melissa Mavers
- Division of Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Bass Center for Childhood Cancer and Blood Diseases, Stanford University School of Medicine, Palo Alto, CA
| | - Richard Aplenc
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | | | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN
| | - Brian T Fisher
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA.,Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA
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40
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Clostridioides difficile Infection and Risk of Acute Graft-versus-Host Disease among Allogeneic Hematopoietic Stem Cell Transplantation Recipients. Transplant Cell Ther 2020; 27:176.e1-176.e8. [PMID: 33830032 DOI: 10.1016/j.jtct.2020.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 10/08/2020] [Accepted: 10/18/2020] [Indexed: 01/15/2023]
Abstract
Clostridioides difficile infection (CDI) is a major cause of infectious diarrhea among allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. The relationship between CDI and acute graft-versus-host disease (aGVHD) has been a topic of interest, as these 2 conditions may influence each other. We studied the temporal relationship of CDI to aGVHD in the first 100 days post-transplantation in a large cohort of allo-HSCT recipients. We performed a retrospective cohort study of adult patients undergoing their first allo-HSCT at our tertiary care medical center between January 1, 2010, and December 31, 2016. Patients were followed for CDI diagnosis, development of aGVHD, and vital status up to day +100 post-transplantation. Descriptive statistics and multivariate Cox models with CDI as a time-varying covariate and aGVHD and high-grade aGVHD as outcomes were used for data analyses. A total of 656 allo-HSCT recipients were included in the analysis. Of these, 419 (64%) developed aGVHD, and 111 (17%) were diagnosed with CDI within the first 100 days post-transplantation. CDI developed before the onset of aGVHD in 72 of the 84 allo-HSCT recipients (85%) with both CDI and aGVHD. Fidaxomicin was used in the treatment of 57 of the 111 CDI cases (50%), whereas vancomycin was used in 52 (47%). Most of the CDI cases (88%) were diagnosed in the peritransplantation period (between day -10 and day +10). The median time to the development of CDI and aGVHD was 3.5 days (range, -7 to 95 days) and 33 days (range, 9 to 98 days) post-transplantation, respectively. Using multivariate Cox model, the following predictors were significantly associated with the development of aGVHD: CDI (adjusted hazard ratio [aHR], 1.52; 95% confidence interval [CI], 1.17 to 1.97; P = .0018), transplantation from a matched related donor (MRD) compared with a matched unrelated donor (aHR, 0.68; 95% CI, 0.54 to 0.85; P = .0003), and myeloablative versus nonmyeloablative conditioning (aHR, 2.45; 95% CI, 1.80 to 3.34; P < .0001), adjusting for age, sex, race, underlying disease, cytomegalovirus CMV serostatus, transplant source, and receipt of antithymocyte globulin (ATG). There was no association between CDI and high-grade aGVHD after adjustment for age, underlying disease, transplant type, intensity of conditioning, and receipt of ATG (aHR, 1.59; 95% CI, 0.95 to 2.66; P = .0755). CDI after allo-HSCT is associated with increased risk of GVHD when no CDI prophylaxis was used. Further studies examining CDI preventive measures, including prophylaxis, as well as the preservation or reconstitution of the gastrointestinal microbiome in the setting of HSCT are warranted.
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Rosignoli C, Petruzzellis G, Radici V, Facchin G, Girgenti M, Stella R, Isola M, Battista M, Sperotto A, Geromin A, Cerno M, Arzese A, Deias P, Tascini C, Fanin R, Patriarca F. Risk Factors and Outcome of C. difficile Infection after Hematopoietic Stem Cell Transplantation. J Clin Med 2020; 9:jcm9113673. [PMID: 33207616 PMCID: PMC7696044 DOI: 10.3390/jcm9113673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/07/2020] [Accepted: 11/11/2020] [Indexed: 12/14/2022] Open
Abstract
Patients who undergo hematopoietic stem cell transplants (HSCT) are at major risk of C. difficile (CD) infection (CDI), the most common cause of nosocomial diarrhea. We conducted a retrospective study, which enrolled 481 patients who underwent autologous (220) or allogeneic HSCT (261) in a 5-year period, with the aim of identifying the incidence, risk factors and outcome of CDI between the start of conditioning and 100 days after HSCT. The overall cumulative incidence of CDI based upon clinical evidence was 5.4% (95% CI, 3.7% to 7.8%), without any significant difference between the two types of procedures. The median time between HSCT and CDI diagnosis was 12 days. Out of 26 patients, 19 (73%) with clinical and symptomatic evidence of CDI were positive also for enzymatic or molecular detection of toxigenic CD; in particular, in 5 out of 26 patients (19%) CD binary toxin was also detected. CDI diagnoses significantly increased in the period 2018-2019, since the introduction in the microbiology lab unit of the two-step diagnostic test based on GDH immunoenzymatic detection and toxin B/binary toxin/027 ribotype detection by real-time PCR. Via multivariate analysis, abdominal surgery within 10 years before HSCT (p = 0.002), antibiotic therapy within two months before HSCT (p = 0.000), HCV infection (p = 0.023) and occurrence of bacterial or fungal infections up to 100 days after HSCT (p = 0.003) were significantly associated with a higher risk of CDI development. The 26 patients were treated with first-line vancomycin (24) or fidaxomicine (2) and only 2 patients needed a second-line treatment, due to the persistence of stool positivity. No significant relationship was identified between CDI and the development of acute graft versus host disease (GVHD) after allogeneic HSCT. At a median follow-up of 25 months (range 1-65), the cumulative incidence of transplant related mortality (TRM) was 16.6% (95% CI 11.7% to 22.4%) and the 3-year overall survival (OS) was 67.0% (95% CI 61.9% to 71.6%). The development of CDI had no significant impact on TRM and OS, which were significantly impaired in the multivariate analysis by gastrointestinal and urogenital comorbidities, severe GVHD, previous infections or hospitalization within two months before HSCT, active disease at transplant and occurrence of infections after HSCT. We conclude that 20% of all episodes of diarrhea occurring up to 100 days after HSCT were related to toxigenic CD infection. Patients with a history of previous abdominal surgery or HCV infection, or those who had received broad spectrum parenteral antibacterial therapy were at major risk for CDI development. CDIs were successfully treated with vancomycin or fidaxomicin after auto-HSCT as well as after allo-HSCT.
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Affiliation(s)
- Chiara Rosignoli
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
| | - Giuseppe Petruzzellis
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
| | - Vera Radici
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
| | - Gabriele Facchin
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
| | - Marco Girgenti
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
| | - Rossella Stella
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
| | - Miriam Isola
- Istituto di Statistica, Dipartimento di Area Medica, Università di Udine, 33100 Udine, Italy;
| | - Martalisa Battista
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
| | - Alessandra Sperotto
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
| | - Antonella Geromin
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
| | - Michela Cerno
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
| | - Alessandra Arzese
- SOC Microbiologia, Azienda Sanitaria Friuli Centrale, 33100 Udine, Italy;
- Dipartimento di Area Medica, Università di Udine, 33100 Udine, Italy
| | - Paola Deias
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
| | - Carlo Tascini
- SOC Malattie Infettive, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy;
| | - Renato Fanin
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
- SOC Malattie Infettive, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy;
| | - Francesca Patriarca
- Clinica Ematologica ed Unità di Terapie Cellulari, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. Maria della Misericordia 10, 33100 Udine, Italy; (C.R.); (G.P.); (V.R.); (G.F.); (M.G.); (R.S.); (M.B.); (A.S.); (A.G.); (M.C.); (P.D.); (R.F.)
- SOC Malattie Infettive, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy;
- Correspondence:
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Patterns of infection and infectious-related mortality in patients receiving post-transplant high dose cyclophosphamide as graft-versus-host-disease prophylaxis: impact of HLA donor matching. Bone Marrow Transplant 2020; 56:818-827. [PMID: 33106541 PMCID: PMC7587539 DOI: 10.1038/s41409-020-01092-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022]
Abstract
Post-transplant cyclophosphamide (PTCy) has become a promising option after allo-SCT, but infections may be more common than in traditional protocols. We herein report 117 consecutive adults who received PTCy-based alloSCT in our hospital: HaploSCT (34%), MRD (19%), and VUD (47%), respectively. The 18-month incidence of severe bacterial, viral, and IFI was 56%, 69%, and 8.7%, without differences between donor type, except for CMV infection and viral hemorrhagic cystitis, which had a higher incidence in the haploSCT cohort (58% vs. 43% and 30% vs. 8% on day +90, p < 0.05). Late infections by conventional respiratory viruses were common in all groups [33/87 (38%)]. The 2-year survival was 72% and did not differ by donor type. IRM at day 30, day 100, and 18 months was 1.7%, 4.4%, and 12%, without differences by donor type (p = 0.7). The primary cause of IRM was bacterial infection (42%). Grade 2–4 acute GvHD was the only independent predictor of IRM. Donor type had no impact on IRM or on survival. In our study, severe infections were common in all donor types using PTCy, with higher rates of early post-engraftment CMV-I and viral HC in haploSCT recipients, although lethal infections were uncommon and similar in all donor types.
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Lee P, Sinha AA, Soma VL, Cruz C, Wang T, Aroniadis O, Herold BC, Frenette PS, Goldman DL, Manwani D. Very low incidence of <i>Clostridioides difficile</i> infection in pediatric sickle cell disease patients. Haematologica 2020; 106:1489-1490. [PMID: 33054107 PMCID: PMC8094088 DOI: 10.3324/haematol.2019.244582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Indexed: 01/01/2023] Open
Affiliation(s)
- Philip Lee
- Department of Pediatrics, The Children's Hospital at Montefiore, Bronx
| | - Arpan A Sinha
- Jimmy Everest Section of Pediatric Hematology/Oncology, The University of Oklahoma Health Sciences Center, Oklahoma City
| | - Vijaya L Soma
- Department of Pediatrics, The Children's Hospital at Montefiore, Bronx, USA; Department of Pediatrics, The Albert Einstein College of Medicine, Bronx
| | - Carlos Cruz
- Department of Pediatrics, The Children's Hospital at Montefiore, Bronx
| | - Tao Wang
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx
| | - Olga Aroniadis
- Department of Medicine, Montefiore Medical Center, Bronx, USA; Department of Medicine, Albert Einstein College of Medicine, Bronx
| | - Betsy C Herold
- Department of Pediatrics, The Children's Hospital at Montefiore, Bronx, USA; Department of Pediatrics, The Albert Einstein College of Medicine, Bronx
| | - Paul S Frenette
- Department of Medicine, Albert Einstein College of Medicine, Bronx
| | - David L Goldman
- Department of Pediatrics, The Children's Hospital at Montefiore, Bronx, USA; Department of Pediatrics, The Albert Einstein College of Medicine, Bronx
| | - Deepa Manwani
- Department of Pediatrics, The Children's Hospital at Montefiore, Bronx, USA; Department of Pediatrics, The Albert Einstein College of Medicine, Bronx.
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Goić-Barišić I, Radić M, Novak A, Rubić Ž, Boban N, Lukšić B, Tonkić M. Vancomycin-resistant Enterococcus faecium COLONIZATION and Clostridium difficile infection in a HEMATOLOGIC patient. Acta Clin Croat 2020; 59:523-528. [PMID: 34177063 PMCID: PMC8212656 DOI: 10.20471/acc.2020.59.03.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Vancomycin-resistant enterococci (VRE), especially Enterococcus faecium, have emerged as significant nosocomial pathogens and patients with impaired host defenses are at a particular risk of VRE infection. The most common occurrence is asymptomatic colonization of the gastrointestinal tract that can persist for a long time and serve as a reservoir for transmission of VRE to other patients. We present a case of a patient who was diagnosed with acute myelogenous leukemia and suffered from bone marrow aplasia following induction therapy. The patient received prolonged broad-spectrum antimicrobial therapy. During hospital stay, the patient developed Clostridium difficile infection (CDI) and was found to be colonized with a strain of Enterococcus faecium resistant to vancomycin during therapy for CDI. This case also highlights the role of risk factors that could contribute to development of resistance, particularly CDI. Early detection of VRE colonization or infection is a crucial component in hospital program designed to prevent transmission of nosocomial infections. Surveillance cultures of such patients should be mandatory.
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Affiliation(s)
| | - Marina Radić
- 1Department of Clinical Microbiology, Split University Hospital Centre, Split, Croatia;2University of Split School of Medicine, Split, Croatia; 3Department of Clinical Epidemiology, Split University Hospital Centre, Split, Croatia; 4Department of Infectious Diseases, Split University Hospital Centre, Split, Croatia
| | - Anita Novak
- 1Department of Clinical Microbiology, Split University Hospital Centre, Split, Croatia;2University of Split School of Medicine, Split, Croatia; 3Department of Clinical Epidemiology, Split University Hospital Centre, Split, Croatia; 4Department of Infectious Diseases, Split University Hospital Centre, Split, Croatia
| | - Žana Rubić
- 1Department of Clinical Microbiology, Split University Hospital Centre, Split, Croatia;2University of Split School of Medicine, Split, Croatia; 3Department of Clinical Epidemiology, Split University Hospital Centre, Split, Croatia; 4Department of Infectious Diseases, Split University Hospital Centre, Split, Croatia
| | - Nataša Boban
- 1Department of Clinical Microbiology, Split University Hospital Centre, Split, Croatia;2University of Split School of Medicine, Split, Croatia; 3Department of Clinical Epidemiology, Split University Hospital Centre, Split, Croatia; 4Department of Infectious Diseases, Split University Hospital Centre, Split, Croatia
| | - Boris Lukšić
- 1Department of Clinical Microbiology, Split University Hospital Centre, Split, Croatia;2University of Split School of Medicine, Split, Croatia; 3Department of Clinical Epidemiology, Split University Hospital Centre, Split, Croatia; 4Department of Infectious Diseases, Split University Hospital Centre, Split, Croatia
| | - Marija Tonkić
- 1Department of Clinical Microbiology, Split University Hospital Centre, Split, Croatia;2University of Split School of Medicine, Split, Croatia; 3Department of Clinical Epidemiology, Split University Hospital Centre, Split, Croatia; 4Department of Infectious Diseases, Split University Hospital Centre, Split, Croatia
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45
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Leon-Rodriguez E, Rivera-Franco MM, Terrazas-Marin RA, Virgen-Cuevas M, Aguirre-Limon MI, Saldaña-González ES, Pacheco-Arias MA, Gomez-Vázquez OR. Infections after hematopoietic cell transplantation are not a burden for mortality at a limited-resource center in a developing country. Transpl Infect Dis 2020; 22:e13414. [PMID: 32668082 DOI: 10.1111/tid.13414] [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: 05/28/2020] [Revised: 06/26/2020] [Accepted: 07/05/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hematopoietic cell transplantation (HCT) outcomes, including infectious complications, change between centers and countries. Thus, the aim of this study was to report the incidence of infections and isolated pathogens among recipients of HCT and the association with mortality at a tertiary referral center in Mexico. METHODS Two hundred and eighty-two patients undergoing autologous or allogeneic HCT between January 2005 and December 2018 at the National Institute of Medical Sciences and Nutricion Salvador Zubiran were included. RESULTS In autologous HCT (n = 176), within the preengraftment and the early postengraftment, 130 (74%) and 31 (18%) recipients presented infections, respectively. Within the preengraftment, the early postengraftment, and the late postengraftment, 81 (76%), 34 (33%), and 58 (60%) allogeneic HCT recipients presented infections, respectively. Non-relapse mortality (NRM) as a result of infections occurred in 1 (0.6%) and 5 (5%) autologous and allogeneic HCT recipients, respectively. CONCLUSIONS Our results demonstrated that despite our limited resources, infections were not a significant burden for NRM among HCT recipients. More importantly, the isolation rates were higher than international studies, which could be explained by the existence of a specialized infectious diseases department and laboratory, which we consider key elements for the establishment of an HCT program worldwide.
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Affiliation(s)
- Eucario Leon-Rodriguez
- Hematopoietic Stem Cell Transplantation Program in Adults, Department of Hematology and Oncology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Monica M Rivera-Franco
- Hematopoietic Stem Cell Transplantation Program in Adults, Department of Hematology and Oncology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Ricardo A Terrazas-Marin
- Hematopoietic Stem Cell Transplantation Program in Adults, Department of Hematology and Oncology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Margarita Virgen-Cuevas
- Department of Infectious Diseases, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Melissa I Aguirre-Limon
- Hematopoietic Stem Cell Transplantation Program in Adults, Department of Hematology and Oncology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Erika S Saldaña-González
- Hematopoietic Stem Cell Transplantation Program in Adults, Department of Hematology and Oncology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Maria A Pacheco-Arias
- Hematopoietic Stem Cell Transplantation Program in Adults, Department of Hematology and Oncology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Oscar R Gomez-Vázquez
- Hematopoietic Stem Cell Transplantation Program in Adults, Department of Hematology and Oncology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
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Weber S, Scheich S, Magh A, Wolf S, Enßle JC, Brunnberg U, Reinheimer C, Wichelhaus TA, Kempf VAJ, Kessel J, Vehreschild MJGT, Serve H, Bug G, Steffen B, Hogardt M. Impact of Clostridioides difficile infection on the outcome of patients receiving a hematopoietic stem cell transplantation. Int J Infect Dis 2020; 99:428-436. [PMID: 32798661 DOI: 10.1016/j.ijid.2020.08.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/02/2020] [Accepted: 08/07/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Clostridioides difficile infections (CDI) are common in autologous (auto-HSCT) or allogenic hematopoietic stem cell transplant (allo-HSCT) recipients. However, the impact of CDI on patient outcomes is controversial. We conducted this study to examine the impact of CDI on patient outcomes. METHODS We performed a retrospective single-center study, including 191 lymphoma patients receiving an auto-HSCT and 276 acute myeloid leukemia (AML) patients receiving an allo-HSCT. The primary endpoint was overall survival (OS). Secondary endpoints were causes of death and, for the allo-HSCT cohort, GvHD- and relapse-free survival (GRFS). RESULTS The prevalence of CDI was 17.6% in the AML allo-HSCT and 7.3% in the lymphoma auto-HSCT cohort. A higher prevalence of bloodstream infections, but no differences concerning OS or cause of death were found for patients with CDI in the auto-HSCT cohort. [AU] In the allo-HSCT cohort, OS and GRFS were similar between CDI and non-CDI patients. However, the leading cause of death was relapse among non-CDI patients, but it was infectious diseases in the CDI group with fewer deaths due to relapse. CONCLUSIONS CDI was not associated with worse survival in patients receiving a hematopoietic stem cell transplantation, and there were even fewer relapse-related deaths in the AML allo-HSCT cohort.
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Affiliation(s)
- Sarah Weber
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany.
| | - Sebastian Scheich
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany.
| | - Aaron Magh
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sebastian Wolf
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Julius C Enßle
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Uta Brunnberg
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Claudia Reinheimer
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany; Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center of Competence for Infection Control, State of Hesse, Germany
| | - Thomas A Wichelhaus
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany; Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center of Competence for Infection Control, State of Hesse, Germany
| | - Volkhard A J Kempf
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany; Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center of Competence for Infection Control, State of Hesse, Germany
| | - Johanna Kessel
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany; Department of Medicine, Infectious Diseases Unit, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Maria J G T Vehreschild
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany; Department of Medicine, Infectious Diseases Unit, University Hospital Frankfurt, Frankfurt am Main, Germany; German Center of Infectious Diseases, Partner site Bonn-Cologne
| | - Hubert Serve
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Gesine Bug
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Björn Steffen
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael Hogardt
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany; Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center of Competence for Infection Control, State of Hesse, Germany
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47
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Mayer EF, Maron G, Dallas RH, Ferrolino J, Tang L, Sun Y, Danziger-Isakov L, Paulsen GC, Fisher BT, Vora SB, Englund J, Steinbach WJ, Michaels M, Green M, Yeganeh N, Gibson JE, Dominguez SR, Nicholson MR, Dulek DE, Ardura MI, Rajan S, Gonzalez BE, Beneri C, Herold BC. A multicenter study to define the epidemiology and outcomes of Clostridioides difficile infection in pediatric hematopoietic cell and solid organ transplant recipients. Am J Transplant 2020; 20:2133-2142. [PMID: 32064754 DOI: 10.1111/ajt.15826] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 01/25/2023]
Abstract
Hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients are at increased risk for Clostridioides difficile infection (CDI). We conducted a multicenter retrospective study to describe the incidence of CDI in children transplanted between January 2010 and June 2013. Nested case-control substudies, matched 1:1 by transplant type, institution, patient age, and time of year (quartile) of transplant, identified CDI risk factors. Cohorts included 1496 HCT and 1090 SOT recipients. Among HCT recipients, 355 CDI episodes were diagnosed in 265 recipients (18.2%). Nested case-control study identified prior history of CDI (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.5-4.7), proton pump inhibitors (PPIs; OR 2.1, 95% CI 1.3-3.4), and exposure to third- (OR 2.4, 95% CI 1.4-4.2) or fourth-generation (OR 2.1, 95% CI 1.2-3.7) cephalosporins as risk factors. Notably, fluoroquinolone exposure appeared protective (OR 0.6, 95% CI 0.3-0.9). Ninety-two episodes of CDI were diagnosed among 79 SOT recipients (7.3%), and exposure to PPIs (OR 2.4, 95% CI 1.1-5.4) and third-generation cephalosporin therapy (OR 3.9, 95% CI 1.4-10.5) were identified as risk factors. Strategies to decrease PPI use and changes in the class of prophylactic antibiotics may impact CDI incidence and warrant further study.
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Affiliation(s)
- Erick F Mayer
- Department of Pediatrics, Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York, USA
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Ronald H Dallas
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jose Ferrolino
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Li Tang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Yilun Sun
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Lara Danziger-Isakov
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Grant C Paulsen
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Brian T Fisher
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Surabhi B Vora
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Janet Englund
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - William J Steinbach
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Marian Michaels
- Department of Pediatrics & Surgery, Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael Green
- Department of Pediatrics & Surgery, Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nava Yeganeh
- Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Joy E Gibson
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Samuel R Dominguez
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Maribeth R Nicholson
- Department of Pediatrics, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel E Dulek
- Department of Pediatrics, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Monica I Ardura
- Department of Pediatrics & Host Defense Program, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sujatha Rajan
- Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York, USA
| | | | - Christy Beneri
- Department of Pediatric, Stony Brook School of Medicine, Stony Brook, New York, USA
| | - Betsy C Herold
- Department of Pediatrics, Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York, USA.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
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48
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Revolinski SL, Munoz-Price LS. Clostridium difficile in Immunocompromised Hosts: A Review of Epidemiology, Risk Factors, Treatment, and Prevention. Clin Infect Dis 2020; 68:2144-2153. [PMID: 30281082 DOI: 10.1093/cid/ciy845] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 09/28/2018] [Indexed: 12/13/2022] Open
Abstract
Clostridium difficile is a significant pathogen in healthcare today, impacting both hospitalized and community-based patients. Immunocompromised patients experience a high incidence of C. difficile infection, ranging from 6% to 33% in the hematology-oncology population and up to 23% among lung transplant recipients, and have a rate of 7.1-8.3 cases per 1000 patient-years in patients with human immunodeficiency virus (HIV). Recurrence of C. difficile infections among immunocompromised patients is also high, with rates up to 40% in both the hematology-oncology population and solid organ transplant recipients. This higher incidence of C. difficile infection and recurrence is believed to be secondary to frequent antimicrobial use, suppressed immune function, increased exposure to healthcare settings, and higher prevalence of C. difficile colonization. This review summarizes published data describing the epidemiology, risk factors for acquisition and infection, treatment, and prevention of C. difficile in hematology-oncology, solid organ transplant, and HIV-infected patients.
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Affiliation(s)
- Sara Lynn Revolinski
- Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee.,School of Pharmacy, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - L Silvia Munoz-Price
- Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee
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49
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Devaux CA, Million M, Raoult D. The Butyrogenic and Lactic Bacteria of the Gut Microbiota Determine the Outcome of Allogenic Hematopoietic Cell Transplant. Front Microbiol 2020; 11:1642. [PMID: 32793150 PMCID: PMC7387665 DOI: 10.3389/fmicb.2020.01642] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/24/2020] [Indexed: 12/12/2022] Open
Abstract
Graft versus host disease (GVHD) is a post-transplant pathology in which donor-derived T cells present in the Peyer's patches target the cell-surface alloantigens of the recipient, causing host tissue damages. Therefore, the GVHD has long been considered only a purely immunological process whose prevention requires an immunosuppressive treatment. However, since the early 2010s, the impact of gut microbiota on GVHD has received increased attention. Both a surprising fall in gut microbiota diversity and a shift toward Enterobacteriaceae were described in this disease. Recently, unexpected results were reported that further link GVHD with changes in bacterial composition in the gut and disruption of intestinal epithelial tight junctions leading to abnormal intestinal barrier permeability. Patients receiving allogenic hematopoietic stem cell transplant (allo-HCT) as treatment of hematologic malignancies showed a decrease of the overall diversity of the gut microbiota that affects Clostridia and Blautia spp. and a predominance of lactic acid bacteria (LAB) of the Enterococcus genus, in particular the lactose auxotroph Enterococcus faecium. The reduced microbiota diversity (likely including Actinobacteria, such as Bifidobacterium adolescentis that cross feed butyrogenic bacteria) deprives the butyrogenic bacteria (such as Roseburia intestinalis or Eubacterium) of their capacity to metabolize acetate to butyrate. Indeed, administration of butyrate protects against the GVHD. Here, we review the data highlighting the possible link between GVHD and lactase defect, accumulation of lactose in the gut lumen, reduction of Reg3 antimicrobial peptides, narrower enzyme equipment of bacteria that predominate post-transplant, proliferation of En. faecium that use lactose as metabolic fuels, induction of innate and adaptive immune response against these bacteria which maintains an inflammatory process, elevated expression of myosin light chain kinase 210 (MLCK210) and subsequent disruption of intestinal barrier, and translocation of microbial products (lactate) or transmigration of LAB within the liver. The analysis of data from the literature confirms that the gut microbiota plays a major role in the GVHD. Moreover, the most recent publications uncover that the LAB, butyrogenic bacteria and bacterial cross feeding were the missing pieces in the puzzle. This opens new bacteria-based strategies in the treatment of GVHD.
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Affiliation(s)
- Christian Albert Devaux
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
- Centre National de la Recherche Scientifique (CNRS), Marseille, France
| | - Matthieu Million
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - Didier Raoult
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
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50
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Solbach P, Chhatwal P, Woltemate S, Tacconelli E, Buhl M, Autenrieth IB, Vehreschild MJGT, Jazmati N, Gerhard M, Stein-Thoeringer CK, Rupp J, Ulm K, Ott A, Lasch F, Koch A, Manns MP, Suerbaum S, Bachmann O. Microbiota-associated risk factors for C. difficile acquisition in hospitalized patients: A prospective, multicentric study. Clin Infect Dis 2020; 73:e2625-e2634. [PMID: 32589701 DOI: 10.1093/cid/ciaa871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Asymptomatic C. difficile colonization is believed to predispose to subsequent C. difficile infection (CDI). While emerging insights into the role of the commensal microbiota in mediating colonization resistance against C. difficile have associated CDI with specific microbial components, corresponding prospectively collected data on colonization with C. difficile are largely unavailable. METHODS C. difficile status was assessed by GDH EIA and real-time PCR targeting the toxin A (tcdA) and B (tcdB) genes. 16S V3 and V4 gene sequencing results from fecal samples of patients tested positive for C. difficile were analyzed by assessing alpha and beta diversity, LefSe, and the Piphillin functional inference approach to estimate functional capacity. RESULTS 1506 patients were recruited into a prospective observational study (DRKS00005335) upon admission into one of five academic hospitals. 936 of them provided fecal samples on admission and at discharge and were thus available for longitudinal analysis. Upon hospital admission, 5.5% (83/1506) and 3.7% (56/1506) of patients were colonized with toxigenic (TCD) and non-toxigenic C. difficile (NTCD), respectively. During hospitalization, 1.7% (16/936) acquired TCD. Risk factors for acquisition of TCD included pre-existing lung diseases, lower GI endoscopy and antibiotics. Species protecting against hospital-related C. difficile acquisition included Gemmiger spp., Odoribacter splanchnicus, Ruminococcus bromii and other Ruminococcus spp.. Metagenomic pathway analysis identified steroid biosynthesis as the most underrepresented metabolic pathway in patients who later acquire C. difficile colonization. CONCLUSIONS Gemmiger spp., Odoribacter splanchnicus, Ruminococcus bromii and other Ruminococci were associated with a decreased risk of C. difficile acquisition.
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Affiliation(s)
- Philipp Solbach
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research (DZIF), partner site Hannover-Braunschweig, Germany.,Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany.,Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Patrick Chhatwal
- German Center for Infection Research (DZIF), partner site Hannover-Braunschweig, Germany.,Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Sabrina Woltemate
- German Center for Infection Research (DZIF), partner site Hannover-Braunschweig, Germany.,Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Internal Medicine 1, Tübingen University Hospital, Tübingen, Germany and Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy.,German Center for Infection Research (DZIF), partner site Tübingen, Germany
| | - Michael Buhl
- German Center for Infection Research (DZIF), partner site Tübingen, Germany.,Institute of Medical Microbiology and Hygiene, Tübingen University Hospital, Tübingen, Germany
| | - Ingo B Autenrieth
- German Center for Infection Research (DZIF), partner site Tübingen, Germany.,Institute of Medical Microbiology and Hygiene, Tübingen University Hospital, Tübingen, Germany
| | - Maria J G T Vehreschild
- 1st Department of Internal Medicine, University Hospital Cologne, Cologne, Germany.,German Center for Infection Research (DZIF), partner site Bonn-Cologne, Germany.,Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Nathalie Jazmati
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Germany.,Institute for Medical Microbiology, Immunology and Hygiene, University Hospital Cologne, Cologne, Germany; currently: Laboratory Dr. Wisplinghoff, Cologne, Germany
| | - Markus Gerhard
- Institute for Medical Microbiology, Immunology and Hygiene, Technische Universität München, Munich, Germany.,German Center for Infection Research (DZIF), partner site Munich, Germany
| | - Christoph K Stein-Thoeringer
- German Center for Infection Research (DZIF), partner site Munich, Germany.,Microbiome and Cancer Research Division, German Center for Cancer Research (DKFZ), Heidelberg, Germany
| | - Jan Rupp
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein, Lübeck, Germany.,German Center for Infection Research (DZIF), partner site Hamburg-Lübeck-Borstel-Riems, Germany
| | - Kurt Ulm
- Institute of Medical Informatics, Statistics and Epidemiology, Technische Universität München, Munich, Germany
| | - Armin Ott
- Institute of Medical Informatics, Statistics and Epidemiology, Technische Universität München, Munich, Germany
| | - Florian Lasch
- Institute for Biometry, Hannover Medical School, Hannover, Germany
| | - Armin Koch
- Institute for Biometry, Hannover Medical School, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research (DZIF), partner site Hannover-Braunschweig, Germany
| | - Sebastian Suerbaum
- German Center for Infection Research (DZIF), partner site Hannover-Braunschweig, Germany.,Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research (DZIF), partner site Munich, Germany.,Chair of Medical Microbiology and Hospital Epidemiology, Max von Pettenkofer Institute, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Oliver Bachmann
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research (DZIF), partner site Hannover-Braunschweig, Germany
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