Impact of surveillance stool culture guided selection of antibiotics in the management of pediatric small bowel transplant recipients

Yield of fungal surveillance cultures in pediatric hematopoietic stem cell transplant patients: a retrospective analysis and survey of current practice

BACKGROUND

Fungal surveillance cultures (FSCs) have been proposed as predictors for development of invasive fungal disease (IFD) and identifiers of the causative organism, although data supporting these are limited and predate universal initiation of antifungal prophylaxis. We aimed to define the epidemiology of fungal colonization and investigate the utility of FSCs for predicting IFD in recipients of pediatric hematopoietic stem cell transplantation (HSCT).

METHODS

FSCs performed from 2007 to 2011 on HSCT patients and laboratory and clinical data were reviewed, and incidence of IFD was determined. Descriptive analyses of culture results were performed to determine the yield of FSCs and their utility. A Web-based survey of national pediatric HSCT providers was undertaken to evaluate current practice and the relevance of our results.

RESULTS

Five thousand six hundred eighteen FSCs from nares, throat, and stool from 360 patients were processed. Of these, 14.8% were positive: 30.3% from stool, 13.2% from throat, and 0.9% from nares; 64.4% of patients had >1 positive FSCs. Thirty (8.3%) patients had IFD. IFD occurred in 7.9% and 10.1% of patients with positive and negative FSCs, respectively (P = .25). Antifungal coverage was changed in 69 patients (29.9%) after positive FSC; 8.6% developed IFD (n = 2 of 6 pathogen concordance with FSC) compared with 6.7% (P = .59) who had no treatment change (n = 3 of 11 concordance). The response rate to the survey was 70.8%; 40% of institutions reported performing routine FSC. Twenty-five percent of providers would not change management based on FSC results; overall rating of usefulness of FSCs was low.

CONCLUSIONS

Although FSCs are commonly performed for pediatric HSCT patients, they have limited utility for predicting IFD.

Six-month incidence of bloodstream infections in intestinal transplant patients

BACKGROUND

Intestinal transplantation has emerged as an established treatment for life-threatening intestinal failure. The most common complication and cause of death is infection. Risk of infection is highest during the first 6 months, as a consequence of maximal immunosuppression, greater than that required for any other organ allograft.

METHODS

We performed a retrospective chart review of all (56) adult and pediatric (<18 years) small bowel transplant patients at our institution between November 2003 and July 2007, and analyzed the 6-month post-transplant incidence of bloodstream infections (BSIs). We evaluated multiple risk factors, including inclusion of a colon or liver, total bilirubin >5, surgical complications, and acute rejection.

RESULTS

A BSI developed in 34 of the 56 patients, with a total of 85 BSI episodes. Of these BSI episodes, 65.9% were due to gram-positive organisms, 34.1% gram-negative organisms, and 2.4% due to fungi. The most common isolates were Enterococcus species, Enterobacter species, Klebsiella species, and coagulase-negative staphylococci. Inclusion of the liver and/or a preoperative bilirubin >5 mg/dL appeared to increase the incidence of BSI (P = 0.0483 and 0.0005, respectively). Acute rejection and colonic inclusion did not appear to affect the incidence of BSI (P = 0.9419 and 0.8248, respectively). The BSI incidence was higher in children (P = 0.0058).

CONCLUSIONS

BSIs are a common complication of intestinal transplantation. Risk factors include age <18, inclusion of the liver, and pre-transplant bilirubin >5. Acute rejection and colon inclusion do not appear to be associated with increased BSI risk.

Intestine transplantation in children: update 2010

This article reviews the current status of pediatric intestinal transplantation, focusing on referral and listing criteria, surgical techniques, patient management, monitoring, complications after transplant, and short- and long-term patient outcome. Intestine transplantation has become the standard of care for children who develop life-threatening complications associated with intestinal failure. The results of intestinal failure treatment have significantly improved in the last decade following the establishment of gut rehabilitation programs and advances in transplant immunosuppressive protocols, surgical techniques, and posttransplant monitoring. The 1-year patient survival is now 80% and more than 80% of the children who survive the transplant are weaned off parenteral nutrition. Early referral for pretransplant assessment and careful follow-up after transplant with prompt recognition and treatment of transplant-related complications are key factors contributing to superior patient outcomes and survival. The best results are being obtained at high-volume centers with survival rates of up to 75% at 5 years.