A study of incidence and characteristics of infections in 476 patients from a single center undergoing autologous blood stem cell transplantation

Early versus Late Fluconazole Prophylaxis in Autologous Hematopoietic Cell Transplantation

Candidemia is a major complication in hematopoietic cell transplantation (HCT), and antifungal prophylaxis with fluconazole decreases the incidence of this complication. We compared 2 strategies for fluconazole prophylaxis in patients with hematologic malignancy undergoing autologous HCT between 1997 and 2017. From 1997 to 2003, fluconazole prophylaxis (400 mg/d) was given to all HCTs, started with the conditioning regimen (early prophylaxis), and given until neutrophil engraftment or the need of non-prophylactic antifungal therapy. From 2004 on, fluconazole (400mg daily) was started only if (and when) the patient developed oral mucositis (late prophylaxis). Among 571 HCT, 270 received early prophylaxis, 112 received late prophylaxis, and 189 did not receive fluconazole because they did not develop oral mucositis. The incidence of candidemia was 1.8% in the early prophylaxis group, 0% in the late prophylaxis group, and 1.1% in the no prophylaxis group (P = .31). Among patients receiving fluconazole, the median duration of prophylaxis was 17 days (range, 6-36 days) in the early prophylaxis group and 6 days (range, 2-16 days) in the late prophylaxis group (P < .001). The initiation of fluconazole prophylaxis guided by the occurrence of oral mucositis (late prophylaxis) was as good as early fluconazole prophylaxis.

Infectious Complications and Multidrug-Resistant Bacteria in Patients With Hematopoietic Stem Cell Transplantation in the First 12 Months After Transplant

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) has been used as treatment in different hematologic and solid malignancies. The aim of this study was to describe the frequency of infectious complications, microbiology, and outcome in patients undergoing HSCT in Mexico during the pre-engraftment period and the impact on mortality rates at 12 months.

METHODS

We conducted a retrospective study of all hematologic malignancies that received HSCT from January 2009 and December 2014, at an oncology reference center.

RESULTS

We included 210 patients: 144 autologous (69%) and 66 allogeneic HSCT (31%). There were 184 infections documented in 109 patients; incidence rate was 47.2 per 1000 neutropenia/days and 22.4 per 1000 hospitalization/days. The main infections reported were pneumonia (n = 40, 19%), bloodstream infections (n = 36, 17.1%), and central line-associated bloodstream infections (n = 28, 13.3%). There were 110 bacteria isolated, 31 were multidrug-resistant (26 were extended-spectrum beta-lactamase; Escherichia coli). There were 25 disseminated or complicated viral infections and 20 invasive fungal diseases. Fourteen patients died in the first 30 days (all related to the infectious process). In multivariate analysis leukemia, more than 2 chemotherapy regimens before transplant and pneumonia were related to 12-month mortality rates.

CONCLUSIONS

Even though infectious processes are frequent in patients with HSCT, multidrug-resistant bacteria were not as frequent as supposed; however, when these microorganisms are involved, mortality rate is increased. It is important to be alert that patients with pneumonia have a significantly increased mortality risk in the first year.

Incidence and risk factors for cytomegalovirus (CMV) reactivation following autologous hematopoietic stem cell transplantation in children

There are limited data on the incidence of CMV reactivation following autologous HSCT (AHSCT) in children. We retrospectively reviewed the incidence and risk factors for CMV reactivation in 72 children who received AHSCT. Twenty-two patients (31%) had positive CMV antigenemia at a median of 23 days (12-31) following transplant. Four patients (6%) required preemptive therapy and all episodes resolved. None of the patients developed CMV disease. Only being CMV seropositivity prior to transplant was significantly associated with CMV reactivation (P < 0.001). The incidence of CMV reactivation following pediatric AHSCT is low, and surveillance beyond 30 days is not needed.

Infections in patients taking Rituximab for hematologic malignancies: two-year cohort study

Background

Rituximab (R) is a chimeric human-murine anti-CD20 monoclonal antibody used to treat B-cell lymphomas. Despite R remarkable activity against malignant cells, there are concerns that R may facilitate the occurrence of infections. This study is aimed to define risk factors for infections, and the potential interaction with time since therapy, in patients undergoing R containing regimens.

Methods

The study has been designed as a multiple failure events historical cohort including all patients who received a R contain regimen at London Royal Free Hospital between May 2007 and April 2009.

Result

One-hundred-eighty-one infections occurred among the 113 enrolled patients (overall incidence rate 3.30 per 1000 person-days). Multivariate analysis showed that lymphocyte counts at nadir, graft versus host disease, HIV sero-status and the type of malignancy were all independently associated with the risk of infection. In addition the analysis of the interaction with the time since the start of therapy provided evidence that different risk factors may increase risk of infections in different times.

Conclusion

This study provides preliminary data to describe the association between several patients’ baseline characteristics and infections during therapy with R.

Ciprofloxacin prophylaxis for patients undergoing high-dose chemotherapy and autologous stem cell transplantation (ASCT) - a single-center experience

PURPOSE

The objective of the study was to evaluate the efficacy of ciprofloxacin prophylaxis for patients undergoing high-dose chemotherapy followed by autologous stem cell transplantation (ASCT).

MATERIALS AND METHODS

The data of 104 patients transplanted at the Department of Hematology Medical University of Lodz between 2005 and 2008 were analyzed. The cohort was divided into two groups depending on the administered ciprofloxacin prophylaxis. Conditioning regimens did not differ significantly among the groups. Multiple myeloma was the main indication for ASCT in both groups.

RESULTS

Ciprofloxacin prophylaxis resulted in a statistically significant reduction of duration of intravenous (IV) antibiotic treatment in the group with prophylaxis (p=0.01). The trend has been observed towards lower prevalence of infectious episodes in the prophylaxis group. Positive blood cultures were similar in both groups with no significant resistance to ciprofloxacin.

CONCLUSION

These data demonstrate that ciprofloxacin prophylaxis is beneficial for patients treated with ASCT following high dose chemotherapy regimen, in terms of the intravenous antibiotics usage. This advantage directly translates into economic benefit and may also induce less bacterial resistance due to less exposure to antibiotics.

Elevated procalcitonin predicts Gram-negative sepsis in haematological patients with febrile neutropenia

OBJECTIVE

To compare semi-quantitative procalcitonin with C-reactive protein in predicting bacteraemia in haematological patients with neutropenic fever.

METHODS

A total of 77 patients treated with intensive chemotherapy for haematological malignancy at Kuopio University Hospital were candidates for study entry. Eleven of these patients did not fulfil the criteria for neutropenic fever, and 66 patients were finally included. Nineteen patients had acute myeloid leukaemia and 47 had received high-dose chemotherapy supported by autologous stem cell transplant. Ninety neutropenic fever episodes in these 66 patients fulfilled the study entry criteria, with microbiological cultures, procalcitonin and C-reactive protein measurements available. Serum procalcitonin and C-reactive protein were analyzed at the onset of each neutropenic fever episode on day 0, and then daily from days 1 to 4.

RESULTS

Bacteraemia was observed in 21 episodes (23%) and the criteria for severe sepsis were fulfilled in 13 episodes (14%). Half of the bacteraemic episodes were caused by Gram-negative bacteria. The kinetics of procalcitonin and C-reactive protein were similar, with increasing levels for 2 to 4 days after the onset of fever. The procalcitonin level on days 1, 2, 3 and 4 was associated with bacteraemia and Gram-negative bacteraemia, but not with the development of severe sepsis. On day 1, a procalcitonin level above 0.5 ng/ml had a sensitivity of 57% and 70% and specificity of 81% and 77% to predict bacteraemia and Gram-negative bacteraemia, respectively.

CONCLUSIONS

An elevated level of procalcitonin within 24 h after the onset of neutropenic fever predicts bacteraemia and Gram-negative bacteraemia in haematological patients.

Clinical practice of obtaining blood cultures from patients with a central venous catheter in place: an international survey

Several aspects of the procedure for obtaining blood cultures are rather controversial. An international survey among 386 experts was performed to investigate the clinical practice of obtaining blood cultures from patients with a central venous catheter (CVC). Among respondents, 64.5% obtain one set of blood cultures from the CVC and one set from the peripheral vein (PV). Other participants answered 'two sets from PV', 'two sets from CVC', 'one from PV', 'one from CVC' and 'other' (9.1%, 4.1%, 8.3%, 7%, and 7%, respectively). Clinicians who, according to the survey, demonstrated that they know the diagnostic performance characteristics of cultures more often obtain one culture from the CVC and one from the PV (73.9% vs. 61.7%, p 0.037).