Antimicrobial prophylaxis in hematopoietic stem cell transplant recipients: heterogeneity of current clinical practice

Abstract

Summary:Antimicrobial agents are commonly used after hematopoietic stem cell transplant (HSCT) to prevent bacterial, viral and fungal infections. A pharmacy practice survey was undertaken to evaluate prevailing practices. The 31 centers evaluated transplanted over 3400 patients in 2001. Over half used bacterial prophylaxis; all with fluoroquinolones. A significantly higher proportion (90-100%) used fungal and viral prophylaxis. Most centers used fluconazole for fungal prophylaxis, but the dose used varied from 400 mg (the recommended dose) to 100 mg. Itraconazole and amphotericin preparations were used by some centers for allograft recipients because of their activity against aspergillosis. Most centers used brief viral prophylaxis for autograft recipients aimed at preventing HSV reactivation. Viral prophylaxis for allograft recipients was usually much more prolonged, reflecting concern over cytomegalovirus infections. Overall, there was significant deviation from recommended guidelines in many of the practices. Our survey suggests that substantial variation exists among transplant centers in their approach to antimicrobial prophylaxis after HSCT. This probably stems from the lack of definitive studies and strong recommendations in several areas, availability of newer agents that have not been adequately studied in the HSCT setting, and a desire to improve outcome before definitive studies are available for newer agents, a process that could take several years.

Varicella zoster virus reactivation after autologous SCT is a frequent event and associated with favorable outcome in myeloma patients

“…20 Clearly, our institutional policy of antiviral prophylaxis with 500 mg acyclovir bid for 3 weeks starting on the day after ASCT is conservative. As a consequence of this study, we have modified our internal guidelines and recommend prolonged antiviral prophylaxis.…”

“…2,3,[17][18][19][20] Clearly, live attenuated VZV vaccination is contraindicated in severely immunocompromised patients undergoing ASCT. In general, patients routinely receive oral antiviral prophylaxis after ASCT to reduce the risk of herpes virus-associated diseases, including HZ.…”

“…The duration of prophylaxis, however, varies greatly between transplant centers. 20 At our center, we followed a restrictive strategy limiting oral antiviral prophylaxis to 3 weeks after ASCT during the study period. In this analysis, we report on the incidence and the subjective disease burden of HZ in a large single-center cohort of consecutive myeloma patients uniformly treated with high-dose melphalan and ASCT in first remission while applying a consistent restrictive oral antiviral prophylaxis.…”

Pretransplant serum ferritin and C-reactive protein as predictive factors for early bacterial infection after allogeneic hematopoietic cell transplantation

“…Therefore, the use of oral fluoroquinolones (FQs) or other antibiotics as antibacterial prophylaxis is strongly considered for HCT recipients, although significant variations have been reported among transplant centers and countries. [3][4][5] Recently, the widespread emergence of FQ-resistant or multidrug-resistant microorganisms in hematologyoncology units has been suggested to compromise the effectiveness of routine antibacterial prophylaxis with FQs in patients undergoing cytotoxic chemotherapy or HCT. [6][7][8][9][10][11][12][13][14] In our center, the isolation rate of FQ-resistant Gramnegative bacilli was high (57.1%) during a period when FQs were routinely administered as antibacterial prophylactic agents; in particular, among isolated Enterobacteriaceae strains, 66.7, 33.3 and 22.2% were resistant to levofloxacin, piperacillin and ceftazidime, respectively.…”

Of Yeasts and Hyphae: A Hematologist’s Approach to Antifungal Therapy

“…Prophylactic micafungin 17 and caspofungin 18 have been studied at daily IV doses of 50 mg. Table 2 shows the distribution of reported start and end dates for antifungal prophylaxis reported in the literature. 13,15,16,[19][20][21][22][23] Prophylaxis should usually be initiated in parallel with the administration of cytotoxic therapy in order to ensure a protective effect at the time of maximal neutropenia and intestinal epithelial damage. Concerns over drug interactions have compelled some investigators to modify the application of triazoles-based prophylaxis until after the administration of cytotoxic therapy.…”