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George B, Kulkarni U, Lionel S, Devasia AJ, Aboobacker FN, Lakshmi KM, Selvarajan S, Korula A, Abraham A, Mathews V. Improving Outcomes with Haploidentical Stem Cell Transplantation [HaploSCT] in Children Using Post-transplant Cyclophosphamide: a Single Center Experience. Indian J Hematol Blood Transfus 2024; 40:375-384. [PMID: 39011253 PMCID: PMC11246385 DOI: 10.1007/s12288-023-01698-3] [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: 04/24/2023] [Accepted: 09/03/2023] [Indexed: 07/17/2024] Open
Abstract
Haplo-identical stem cell transplant using post-transplant cyclophosphamide is increasingly being used in children without a matched sibling donor. Between 2010 and June 2021, 127 children underwent 138 transplants with a median age of 7.1 years for malignant and non-malignant disorders. Conditioning regimens included both myeloablative and reduced intensity regimens with peripheral blood stem cells as the main graft source. Engraftment occurred in 113 [81.9%] at a median of 16 days [range: 10-32] with primary graft failure in 10.2%. Cumulative incidence of grade II-IV acute graft versus host disease (GVHD) was 49.5% and chronic GVHD in 40.7%. Majority [92.7%] had at least one infection with 31% incidence of bacterial infection, 76% incidence of viral and 16% incidence of fungal infection. The 2-year overall survival (OS) is 54.9 ± 4.6% with a lower survival among young children aged 0-5 years [28.2 ± 6.4%] compared to 5-10 years [71.3 ± 6.8%] and 11-15 years [55.7 ± 8.8%] [p = 0.032]. 2-year OS has gradually improved from 25.0 ± 2.1% for 2010-2013 to 47.5 ± 6.2% for 2014-2017 and 67.1 ± 6.6% for 2018-2021 [p = 0.049]. On multivariate analysis, bacterial infection [p = 0.017], invasive fungal disease [p = 0.002] and graft failure [p = 0.029] negatively impacted overall survival. Haplo-identical SCT with post-transplant cyclophosphamide is a reasonable option for children who do not have a matched sibling donor. Strategies to reduce graft failure, infection related mortality and GVHD needs to be explored.
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Affiliation(s)
- Biju George
- Department of Haematology, Christian Medical College, Vellore, India
| | - Uday Kulkarni
- Department of Haematology, Christian Medical College, Vellore, India
| | - Sharon Lionel
- Department of Haematology, Christian Medical College, Vellore, India
| | - Anup J Devasia
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Kavitha M Lakshmi
- Department of Haematology, Christian Medical College, Vellore, India
| | - Sushil Selvarajan
- Department of Haematology, Christian Medical College, Vellore, India
| | - Anu Korula
- Department of Haematology, Christian Medical College, Vellore, India
| | - Aby Abraham
- Department of Haematology, Christian Medical College, Vellore, India
| | - Vikram Mathews
- Department of Haematology, Christian Medical College, Vellore, India
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Gonçalves LA, Anjos BB, Tavares BM, Marchi AP, Côrtes MF, Higashino HR, de Carvalho Moraes BDG, Bampi JVB, Pinheiro LD, Spadao FDS, Rocha V, Guimarães T, Costa SF. Colonization by Extended-Spectrum β-Lactamase-Producing Enterobacterales and Bacteremia in Hematopoietic Stem Cell Transplant Recipients. Antibiotics (Basel) 2024; 13:448. [PMID: 38786176 PMCID: PMC11118097 DOI: 10.3390/antibiotics13050448] [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: 03/24/2024] [Revised: 05/08/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Assessing the risk of multidrug-resistant colonization and infections is pivotal for optimizing empirical therapy in hematopoietic stem cell transplants (HSCTs). Limited data exist on extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) colonization in this population. This study aimed to assess whether ESBL-E colonization constitutes a risk factor for ESBL-E bloodstream infection (BSI) and to evaluate ESBL-E colonization in HSCT recipients. METHODS A retrospective analysis of ESBL-E colonization and BSI in HSCT patients was conducted from August 2019 to June 2022. Weekly swabs were collected and cultured on chromogenic selective media, with PCR identifying the β-lactamase genes. Pulsed-field gel electrophoresis (PFGE) and whole-genome sequencing (WGS) assessed the colonizing strains' similarities. RESULTS Of 222 evaluated HSCT patients, 59.45% were colonized by ESBL-E, with 48.4% at admission. The predominant β-lactamase genes were blaTEM (52%) and blaSHV (20%). PFGE analysis did not reveal predominant clusters in 26 E. coli and 15 K. pneumoniae strains. WGS identified ST16 and ST11 as the predominant sequence types among K. pneumoniae. Thirty-three patients developed thirty-five Enterobacterales-BSIs, with nine being third-generation cephalosporin-resistant. No association was found between ESBL-E colonization and ESBL-BSI (p = 0.087). CONCLUSIONS Although the patients presented a high colonization rate of ESBL-E upon admission, no association between colonization and infection were found. Thus, it seems that ESBL screening is not a useful strategy to assess risk factors and guide therapy for ESBL-BSI in HSCT-patients.
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Affiliation(s)
- Luiza Arcas Gonçalves
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Beatriz Barbosa Anjos
- Laboratório de Investigação Médica em Protozoologia, Bacteriologia e Resistência Antimicrobiana-LIM/49, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Bruno Melo Tavares
- Departamento de Controle de Infecção Hospitalar, Instituto Central, Moléstias Infecciosas e Parasitárias, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Ana Paula Marchi
- Laboratório de Investigação Médica em Protozoologia, Bacteriologia e Resistência Antimicrobiana-LIM/49, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Marina Farrel Côrtes
- Laboratório de Investigação Médica em Protozoologia, Bacteriologia e Resistência Antimicrobiana-LIM/49, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Hermes Ryoiti Higashino
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Bruna Del Guerra de Carvalho Moraes
- Laboratório de Investigação Médica em Protozoologia, Bacteriologia e Resistência Antimicrobiana-LIM/49, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - José Victor Bortolotto Bampi
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Liliane Dantas Pinheiro
- Departamento de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Fernanda de Souza Spadao
- Departamento de Controle de Infecção Hospitalar, Instituto Central, Moléstias Infecciosas e Parasitárias, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Vanderson Rocha
- Departamento de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Thais Guimarães
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
- Departamento de Controle de Infecção Hospitalar, Instituto Central, Moléstias Infecciosas e Parasitárias, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Silvia Figueiredo Costa
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
- Laboratório de Investigação Médica em Protozoologia, Bacteriologia e Resistência Antimicrobiana-LIM/49, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo 05403-000, Brazil
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Ghosh S, Bhattacharya S, Goel G, Deshmukh RA, Javed R, Roychowdhury M, Sinha S, De MS, Nag A, Kumar J, Bhave SJ, Nair R, Chandy M. Hematopoietic stem-cell transplantation in a zoo of multidrug-resistant organisms: Data from a cancer center in eastern India. Transpl Infect Dis 2023; 25 Suppl 1:e14072. [PMID: 37260056 DOI: 10.1111/tid.14072] [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: 12/25/2022] [Revised: 04/19/2023] [Accepted: 05/15/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Infections by multidrug-resistant organisms (MDRO) are a major hurdle in hematopoietic stem-cell transplants (HSCTs). Conditioning regimens lead to mucosal barrier injury, which in-turn leads to transmigration of gut bacteria and sepsis. Pre-transplant stool and throat surveillance cultures can guide empirical antibiotic policy during the neutropenic period. In this paper, we document colonization with MDRO in pre-transplant surveillance cultures and the correlation with bloodstream infections in HSCT patients and analyze transplant outcomes with respect to these infections. METHODS A single-center, retrospective study on HSCT was performed between January 2021 and December 2021. The incidence of bacterial infections, percentage of MDROs, correlation with pre-transplant stool/throat surveillance cultures, and their impact on overall 100-day and post-100-day to 6-month post-transplant survival were analyzed. RESULTS Sixty-four patients were included in the study. Pre-transplant stool surveillance cultures were positive for MDRO in 85.9% of patients. Almost half (48.5%) of the isolates were positive for carbapenemase-producing genes (mainly New Delhi metallo-beta-lactamase-1 [NDM-1] and oxacillinase-48 [OXA-48]). Eighteen patients (18/64, 28%) had a positive blood culture for MDRO in the peri-engraftment neutropenic period. Correlation between surveillance and blood cultures was seen in 61% (11/18) of patients. All-cause mortality was 14.1% (9/64) and 25% (16/64) in patients at 100 days and 6 months post-HSCT, respectively. The 100-day and post-100-day all-cause mortality rates were higher in patients with Gram-negative MDRO bloodstream infections (p < .012 and <.008, respectively). CONCLUSION MDRO infections can adversely affect HSCT outcomes. Pre-transplant stool and throat surveillance cultures may guide empirical antibiotic policy and lead to favorable transplant outcomes.
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Affiliation(s)
- Shouriyo Ghosh
- Department of Clinical Haematology and BMT, Tata Medical Center, Kolkata, West Bengal, India
| | - Sanjay Bhattacharya
- Department of Microbiology, Tata Medical Center, Kolkata, West Bengal, India
| | - Gaurav Goel
- Department of Microbiology, Tata Medical Center, Kolkata, West Bengal, India
| | | | - Rizwan Javed
- Department of Clinical Haematology and BMT, Tata Medical Center, Kolkata, West Bengal, India
| | - Mita Roychowdhury
- Department of Clinical Haematology and BMT, Tata Medical Center, Kolkata, West Bengal, India
| | - Subir Sinha
- Department of Biostatistics, Tata Medical Center, Kolkata, West Bengal, India
| | - Maitrayee Sarkar De
- Hospital Infection Control Committee, Tata Medical Center, Kolkata, West Bengal, India
| | - Arijit Nag
- Department of Clinical Haematology and BMT, Tata Medical Center, Kolkata, West Bengal, India
| | - Jeevan Kumar
- Department of Clinical Haematology and BMT, Tata Medical Center, Kolkata, West Bengal, India
| | - Saurabh Jayant Bhave
- Department of Clinical Haematology and BMT, Tata Medical Center, Kolkata, West Bengal, India
| | - Reena Nair
- Department of Clinical Haematology and BMT, Tata Medical Center, Kolkata, West Bengal, India
| | - Mammen Chandy
- Department of Clinical Haematology and BMT, Tata Medical Center, Kolkata, West Bengal, India
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Willems RPJ, van Dijk K, Vehreschild MJGT, Biehl LM, Ket JCF, Remmelzwaal S, Vandenbroucke-Grauls CMJE. Incidence of infection with multidrug-resistant Gram-negative bacteria and vancomycin-resistant enterococci in carriers: a systematic review and meta-regression analysis. THE LANCET. INFECTIOUS DISEASES 2023; 23:719-731. [PMID: 36731484 DOI: 10.1016/s1473-3099(22)00811-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/17/2022] [Accepted: 11/29/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Carriers of multidrug-resistant bacteria are at risk of infections with these bacteria; the precise size of this risk is unclear. We aimed to quantify the effect of gut colonisation on subsequent risk of infection with multidrug-resistant bacteria. METHODS We performed a systematic review and meta-regression analysis. We searched PubMed, Embase, Web of Science Core Collection, and Google Scholar for follow-up studies published from Jan 1, 1995, to March 17, 2022, that measured the incidence of infections with multidrug-resistant Gram-negative bacteria (MDR-GNB) and from Jan 1, 1995, to March 15, 2022, that measured the incidence of infections with vancomycin-resistant enterococci (VRE). We included original cohort studies and case-control studies that used incidence-density sampling, included 50 or more patients with enteric colonisation or positive urinary samples as a surrogate marker of colonisation, or both, and analysed infections clearly preceded by colonisation. We did not use any language restrictions. We excluded studies not reporting length of follow-up. Summary data were extracted and independently cross-verified by two authors. Carriage was defined as MDR-GNB or VRE, detected in faecal or urinary cultures. Our primary outcomes were cumulative incidence and incidence density of infection in patients colonised by multidrug-resistant bacteria. To estimate pooled incidences, general linearised mixed-effects meta-regressions were used, adjusting for varying follow-up durations. This study is registered with PROSPERO, CRD42020222415. FINDINGS Of the 301 studies identified, 44 studies (26 on MDR-GNB, 14 on VRE, and four on both MDR-GNB and VRE) from 14 countries were retained for qualitative synthesis, 40 of which were analysed with meta-regression, comprising data for 14 049 patients colonised with multidrug-resistant bacteria. The pooled cumulative incidence of infection was 14% (95% CI 10-18; p<0·0001) at a median follow-up time of 30 days for MDR-GNB (845 cases of infection in 9034 patients colonised) and 8% (5-13; p<0·0001) at 30 days for VRE (229 cases of infection in 4747 patients colonised). Infection incidence density (4·26 infections per 1000 patient-days; 95% CI 1·69-6·82) and cumulative incidence of infection (19%, 95% CI 15-25; p<0·0001; 602 cases of infection in 4547 patients colonised) were highest for carbapenem-resistant Gram-negative bacteria at 30 days. Risk of bias was rated low to moderate. INTERPRETATION The risk of infection was substantial, with the highest risk for patients colonised with carbapenem-resistant Gram-negative bacteria and the lowest in patients with VRE. These data might help to guide prophylactic and treatment decisions and form a valuable resource for planning clinical trials on targeted prevention. FUNDING The Netherlands Organization for Health Research and Development.
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Affiliation(s)
- Roel P J Willems
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam Infection and Immunity Institute, Amsterdam, Netherlands.
| | - Karin van Dijk
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam Infection and Immunity Institute, Amsterdam, Netherlands
| | - Maria J G T Vehreschild
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany; German Centre of Infection Research (partner site Bonn-Cologne), Cologne, Germany; Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Lena M Biehl
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany; German Centre of Infection Research (partner site Bonn-Cologne), Cologne, Germany
| | - Johannes C F Ket
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Sharon Remmelzwaal
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Christina M J E Vandenbroucke-Grauls
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam Infection and Immunity Institute, Amsterdam, Netherlands; Department of Clinical Medicine and Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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Varla H, Meena S, Swaminathan VV, Chandar R, Munnusamy MK, Ramakrishnan B, Karmegam D, Grace J, Jayakumar I, Uppuluri R, Raj R. Risk Factors for Neutropenic Sepsis Related Mortality in Children Undergoing Allogenic Hematopoietic Stem Cell Transplantation. Indian J Hematol Blood Transfus 2023; 39:1-6. [PMID: 36699434 PMCID: PMC9868024 DOI: 10.1007/s12288-021-01486-x] [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: 05/29/2021] [Accepted: 08/19/2021] [Indexed: 01/28/2023] Open
Abstract
We aimed to analyze infections in children undergoing hematopoietic stem cell transplantation (HSCT) until engraftment. The spectrum and risk factors associated will help plan interventions to reduce mortality. We performed a retrospective analysis on the infections, associated risk factors, and mortality until engraftment in children up to 18 years of age undergoing HSCT from January 2017 to August 2020. A total of 399 children were included, with a male: female ratio of 1.9:1, with matched related donor HSCT in 36.6%, a matched unrelated donor in 18.3%, and haploidentical HSCT in 38.1% of children. Culture positive bacteremia was documented in 22.1% transplants with gram-negative bacteria (GNB) isolated in 71/88 (80%). Among the GNB, the predominant organism was Klebsiella pneumonia in 38 (53%), E.coli in 16 (22%), Pseudomonas in 9 (12%). Carbapenem resistance was documented in 24/71 (33%). The incidence of possible, probable, and proven fungal infections in the cohort was 63 (15%), 28 (7%), and 6 (1.5%), respectively. Mortality up to engraftment due to sepsis in our cohort is 3.3% (n = 13). There was a significant association between mortality and a perianal focus (30.8%, p value 0.029) and the presence of carbapenem resistance (38%, p value 0.002). Mortality among those who developed proven fungal infections was significantly higher than those with bacteremia (p value 0.004). Our study has identified fungal sepsis and carbapenem-resistant GNB sepsis as high-risk groups for mortality. Risk directed interventions in these groups would help ensure survival and optimal outcomes.
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Affiliation(s)
- Harika Varla
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Padma Complex, Anna Salai, 320, Teynampet, Chennai, 600035 India
| | - Satishkumar Meena
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Padma Complex, Anna Salai, 320, Teynampet, Chennai, 600035 India
| | - Venkateswaran Vellaichamy Swaminathan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Padma Complex, Anna Salai, 320, Teynampet, Chennai, 600035 India
| | - Rumesh Chandar
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Padma Complex, Anna Salai, 320, Teynampet, Chennai, 600035 India
| | - Mohan Kumar Munnusamy
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Padma Complex, Anna Salai, 320, Teynampet, Chennai, 600035 India
| | | | - Deepa Karmegam
- Department of Nursing, Apollo Hospitals, Padma Complex, Anna Salai, 320, Teynampet, Chennai, 600035 India
| | - Jerlin Grace
- Department of Nursing, Apollo Hospitals, Padma Complex, Anna Salai, 320, Teynampet, Chennai, 600035 India
| | - Indira Jayakumar
- Department of Pediatric Critical Care, Apollo Hospitals, Padma Complex, Anna Salai, 320, Teynampet, Chennai, 600035 India
| | - Ramya Uppuluri
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Padma Complex, Anna Salai, 320, Teynampet, Chennai, 600035 India
| | - Revathi Raj
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Padma Complex, Anna Salai, 320, Teynampet, Chennai, 600035 India
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Mendes ET, Salomão MC, Tomichi LM, Oliveira MS, Graça M, Rossi F, Sapadao F, Guimarães T, Rocha V, Costa SF. Effectiveness of surveillance cultures for high priority multidrug-resistant bacteria in hematopoietic stem cell transplant units. Rev Inst Med Trop Sao Paulo 2021; 63:e77. [PMID: 34755816 PMCID: PMC8580484 DOI: 10.1590/s1678-9946202163077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 09/15/2021] [Indexed: 12/25/2022] Open
Abstract
Surveillance strategies to detect colonization are an important tool to prevent
and control the spread of microorganisms in hematopoietic stem cell transplant
(HSCT) units. The aim of this study was to evaluate routine surveillance
cultures for screening colonization and infection by carbapenem-resistant
Enterobacteriaceae (CRE), carbapenem-resistant Pseudomonas
aeruginosa (CRPa), and vancomycin-resistant enterococci (VRE).
Surveillance cultures were collected (1,323 samples) from 200 patients admitted
to an HSCT unit over one year; swabs were taken on admission and then weekly. We
compared the positivity of cultures for each site, agent, clinical and
epidemiological data according to the colonization status. Infection due to
multidrug-resistant organisms (MDROs) occurred in 52 (21.5%) patients, 45
(86.5%) due to blood stream infection; 12 (23%) patients had a positive
surveillance culture before the infection. Cultures of 554 (41.8%) samples were
performed for CRPa, 413 (31.2%) for VRE and 356 (27%) for CRE. Of these, 179
(13.5%) were positive. Colonization by any MDRO, CRE or CRPa was associated with
increased risk of infection (P < 0.05), but not with death.
Previous colonization by an MDRO was a significant risk for infection by these
pathogens, specially by CRE. Overall, rectal swabs had the highest positivity
rate compared with other sites, oropharynx swabs were an option for CRPa, and
fecal cultures showed low positivity. Although the impact of the strategy on the
mortality of patients undergoing HSCT is not clear, routine VRE surveillance
should be questioned with regard to patients undergoing auto-HSCT due to the
additional cost and little impact on survival rates.
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Affiliation(s)
- Elisa Teixeira Mendes
- Pontifícia Universidade Católica de Campinas, Centro de Ciências da Vida, Programa de Pós-Graduação em Ciências da Saúde, Campinas, São Paulo, Brazil
| | - Matias Chiarastelli Salomão
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Doenças Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil
| | - Lísia Moura Tomichi
- Universidade do Rio Verde, Hospital de Doenças Tropicais, Aparecida de Goiânia, Goiás, Brazil
| | - Maura Salaroli Oliveira
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Doenças Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil
| | - Mariana Graça
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo, Laboratório de Microbiologia, São Paulo, São Paulo, Brazil
| | - Flavia Rossi
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório Central, Divisão de Microbiologia, São Paulo, São Paulo, Brazil
| | - Fernanda Sapadao
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Doenças Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil
| | - Thais Guimarães
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Doenças Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil
| | - Vanderson Rocha
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Hematologia e Hemoterapia, São Paulo, São Paulo, Brazil
| | - Silvia Figueiredo Costa
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Doenças Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil.,Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo, Laboratório de Microbiologia, São Paulo, São Paulo, Brazil
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7
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Haploidentical transplantation is feasible and associated with reasonable outcomes despite major infective complications-A single center experience from India. Transplant Cell Ther 2021; 28:45.e1-45.e8. [PMID: 34607073 DOI: 10.1016/j.jtct.2021.09.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/08/2021] [Accepted: 09/26/2021] [Indexed: 11/23/2022]
Abstract
Haploidentical stem cell transplantation (SCT) using post-transplantation cyclophosphamide for graft-versus-host disease (GVHD) prophylaxis is a reasonable therapeutic option for patients who do not have a matched sibling donor. Between 2010 and June 2020, 257 patients underwent 269 Haploidentical transplantations, including 122 children. Indications included both malignant (56.8%) and non-malignant (43.2%) diseases. Conditioning regimens included both myeloablative (57.6%) and nonmyeloablative regimens (42.4%). Peripheral blood stem cells were the predominant graft source (96.2%). Based on the disease risk index, patients were classified into early-, intermediate-, and late-stage disease. Engraftment was seen in 205 patients (76.2%) whereas 39 (14.4%) died before engraftment and 23 (8.6%) had primary graft failure. The cumulative incidence of grade II-IV acute GVHD was 47.8% with a 23.9% incidence of grade III-IV acute GVHD. Chronic GVHD was seen in 41.9% with a 15.4% incidence of extensive chronic GVHD. More than 90% had at least 1 documented infection with a 44% incidence of bacterial, 71% viral, and 38% fungal infection. The 2-year overall survival is 40.5% ± 3.2% with a higher survival among children (48.2% ± 3.4%) compared to adults (34.2% ± 4.1%). Survival was poor with late-stage disease (23.6% ± 4.3%) compared to early- (62.5% ± 7.5%) and intermediate-stage (50.3% ± 4.3%). Factors adversely affecting survival included older age of patient (P = .007), late disease status (P = .000), nonmyeloablative conditioning regimen (P = .003), bone marrow as graft source (P = .006), presence of acute GVHD (P = .069), primary graft failure (P = .000), and presence of a documented bacterial (P = .000) and fungal infection (P = .000). On multivariate analysis, older age (P = .027), presence of acute GVHD (P = .033), documented bacterial infection (P = .000), documented fungal infection (P = .000) and primary graft failure (P = .012) continued to remain significant. Haploidentical SCT offers a reasonable chance of cure for patients with both malignant and nonmalignant hematological diseases. Strategies to reduce aGVHD and infection related mortality needs to be explored further. © 20XX American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.
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Kaundal S, Jandial A, Singh H, Chopra M, Kasudhan KS, Khaire N, Khadwal A, Prakash G, Jain A, Suri V, Patil A, Arora A, Sharma V, Ray P, Malhotra P, Lad DP. Impact of broad-spectrum antibiotic exposures and multidrug-resistant gram-negative bacteremia on hematopoietic cell transplantation outcomes. Transpl Infect Dis 2021; 23:e13717. [PMID: 34431187 DOI: 10.1111/tid.13717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/10/2021] [Accepted: 08/15/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION There is a close association between the use of broad-spectrum antibiotics, gut microbiome alteration, multidrug resistant (MDR) gram-negative bacilli (GNB) bacteremia, graft versus host disease (GVHD), and mortality post-allogeneic hematopoietic cell transplantation (allo-HCT). This study reports the impact of the high use of carbapenems and colistin and MDR bacteremia pre- and post-HCT on HCT outcomes. METHODS This was a single-center, partial retrospective, and prospective study from 2016 to 2020. Both pre- and post-HCT antibiotic exposures and blood culture/sensitivity were recorded. MDR GNB was defined as either non-susceptibility to third-generation cephalosporin or carbapenems. In the absence of positive cultures, the treating physician escalated antibiotics from third-generation cephalosporins to carbapenem and/or colistin as per clinical discretion. De-escalation policy was not strictly enforced. RESULTS MDR GNB bacteremia was seen in 29 of 76 (38%) of patients peri-HCT. The utilization rates for carbapenems and colistin was significantly higher in the cohort with MDR GNB bacteremia pre-HCT (70% vs. 32%, p = 0.002 and 31% vs. 6.4%, p = 0.007, respectively) and post-HCT (100% vs. 74.5%, p = 0.002, and 55.2% vs. 8.5%, p < 0.0001, respectively). The cohort with MDR GNB bacteremia had significantly more severe acute GVHD at day+100 (45% vs. 17.5%, p = 0.009). The median survival was 204 days compared to not reached in the cohort without any MDR GNB bacteremia (p = 0.005). CONCLUSION This study shows pre- and post-HCT MDR GNB bacteremia is associated with an increased risk of severe acute GVHD and mortality. Patients with MDR GNB bacteremia had higher exposure to pre- and post-HCT carbapenems and colistin.
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Affiliation(s)
- Shaweta Kaundal
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aditya Jandial
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harmandeep Singh
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhu Chopra
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kripa Shanker Kasudhan
- Department of Clinical Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khaire
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alka Khadwal
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Prakash
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arihant Jain
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Suri
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amol Patil
- Department of Clinical Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Arora
- Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pallab Ray
- Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepesh P Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Multidrug-resistant, gram-negative infections in high-risk haematologic patients: an update on epidemiology, diagnosis and treatment. Curr Opin Infect Dis 2021; 34:314-322. [PMID: 34117191 DOI: 10.1097/qco.0000000000000745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Multidrug-resistant Gram-negative bacilli (MDR-GNB) infections are a significant cause of morbidity and mortality in high-risk hematologic patients. Early diagnosis and management of antibiotic treatment in these patients is a challenge for physicians. This review focuses on the latest literature reports that concern the epidemiology, diagnosis and treatment of MDR-GNB infections in this population. RECENT FINDINGS High-risk haematological patients have several risk factors that make them particularly susceptible to MDR-GNB infections. Few studies have examined the implementation of rapid diagnostic methods for multidrug resistance, and their impact on management in this population. Inappropriate empiric antibiotic treatment in these patients has been described frequently and is associated with poor outcomes. SUMMARY Knowledge of the local epidemiology of MDR-GNB is a basic requirement to guide empiric antibiotic treatments in each centre. New diagnosic tests might help in faster identification of MDR-GNB infections. Appropriate empiric antibiotic treatment is crucial for improving patients' prognosis. Important strategies to reduce inadequate antibiotic treatment include better risk stratification for MDR-GNB infection and the introduction of new, more broad-spectrum antibiotic therapies.
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George B, Lionel S, Selvarajan S, Abubacker FN, Korula A, Devasia AJ, Kulkarni U, Lakshmi KM, Sindhuvi E, Abraham A, Mathews V. An Antithymocyte Globulin-Free Conditioning Regimen Using Fludarabine and Cyclophosphamide Is Associated with Good Outcomes in Patients Undergoing Matched Related Family Donor Transplantation for Aplastic Anemia. Transplant Cell Ther 2021; 27:409.e1-409.e6. [PMID: 33965181 DOI: 10.1016/j.jtct.2021.01.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 01/26/2021] [Accepted: 01/31/2021] [Indexed: 02/02/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) using fludarabine (Flu)-based conditioning regimens are being increasingly being used in patients with aplastic anemia (AA). We describe an antithymocyte globulin (ATG)-free conditioning regimen consisting of Flu and cyclophosphamide (Cy) in patients undergoing matched related donor (MRD) HSCT for AA. Between 2004 and 2019, 212 patients underwent MRD HSCT using Flu (30 mg/m2/day for 6 days) and Cy (60 mg/kg/day for 2 days) for conditioning. The graft source was peripheral blood stem cells in all patients. Graft-versus-host disease (GVHD) prophylaxis consisted mainly of cyclosporine and methotrexate, although 41 patients received post-transplantation Cy as part of a study. Engraftment occurred in 91% of patients at a median of 16 days, whereas 4 patients (1.8%) experienced primary graft failure and 15 (7.1%) died before achieving engraftment. Toxicity was minimal. The incidence of grade II-IV acute GVHD (aGVHD) was 27.9%, and that of grade III-IV aGVHD was 11.3%. Chronic GVHD occurred in 41.6%. 80% were free of immunosuppression at 60 months and long-term complications were seen in 8.4%. At a median of 46 months, 158 patients were alive and well, with a 5-year overall survival (OS) of 75.3 ± 3.0%. The 5-year OS was 80.6 ± 4.1% for patients age <20 years (n = 93), 74.5 ± 4.6% for those age 20 to 40 years (n = 91), and 59.7 ± 9.5% for those age >40 years (n = 28) (P = .11). Patients classified as low risk had better OS compared with those at high risk (93.2 ± 2.9% versus 65.7 ± 4.1%; P = .000). Factors affecting OS on multivariate analysis included aGVHD (P = .02) and graft failure (P = .000). This large series using Flu/Cy for conditioning before MRD HSCT confirms good outcomes in patients with AA, with excellent outcomes in low-risk patients. Suitable modifications are needed to improve outcomes in high-risk patients.
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Affiliation(s)
- Biju George
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India.
| | - Sharon Lionel
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Sushil Selvarajan
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Fouzia N Abubacker
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Anu Korula
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Anup J Devasia
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Uday Kulkarni
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Kavitha M Lakshmi
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Eunice Sindhuvi
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Aby Abraham
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Vikram Mathews
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
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Sahitya DSK, Jandiyal A, Jain A, Senapati J, Nanda S, Aggarwal M, Kumar P, Mohapatra S, Ray P, Malhotra P, Mahapatra M, Dhawan R. Prevention and management of carbapenem-resistant Enterobacteriaceae in haematopoietic cell transplantation. Ther Adv Infect Dis 2021; 8:20499361211053480. [PMID: 34733507 PMCID: PMC8558808 DOI: 10.1177/20499361211053480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/28/2021] [Indexed: 12/19/2022] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) infections are associated with high morbidity and mortality rates in haematopoietic cell transplantation (HCT) recipients. Factors like mucositis, neutropenia, prolonged hospital stay, and frequent use of prophylactic antimicrobials make HCT recipients especially susceptible to CRE infections. Low culture positivity rates, delay in microbiological diagnosis, and resistance to empirical antimicrobial therapy for febrile neutropenia are responsible for high mortality rates in HCT recipients infected with CRE. In this review we discuss the epidemiology, diagnosis, and management of CRE infections with particular emphasis on patients undergoing HCT. We emphasise the need for preventive strategies like multidisciplinary antimicrobial stewardship, and pre-emptive screening for CRE colonisation in prospective HCT patients as measures to mitigate the adverse impact of CRE on HCT outcomes. Newer diagnostic tests like polymerase chain reaction and matrix-assisted laser desorption ionisation-time of flight (MALDI-TOF) assay that enable earlier and better identification of CRE isolates are discussed. Antimicrobial agents available against CRE, including newer agents like ceftazidime-avibactam and meropenem-vaborbactam, have been reviewed. We also discuss the data on promising experimental treatments against CRE: phage therapy and healthy donor faecal microbiota transplant. Finally, this review puts forth recommendations as per existing literature on diagnosis and management of CRE infections in blood and marrow transplant (BMT) unit.
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Affiliation(s)
| | - Aditya Jandiyal
- Postgraduate Institute of Medical Education & Research, Chandigarh, Chandigarh, India
| | - Arihant Jain
- Postgraduate Institute of Medical Education & Research, Chandigarh, Chandigarh, India
| | - Jayastu Senapati
- All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | - Saumya Nanda
- Lady Hardinge Medical College, New Delhi, New Delhi, India
| | - Mukul Aggarwal
- All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | - Pradeep Kumar
- All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | - Sarita Mohapatra
- All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | - Pallab Ray
- Postgraduate Institute of Medical Education & Research, Chandigarh, Chandigarh, India
| | - Pankaj Malhotra
- Postgraduate Institute of Medical Education & Research, Chandigarh, Chandigarh, India
| | | | - Rishi Dhawan
- All India Institute of Medical Sciences, New Delhi, New Delhi 110029, India
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