Early vancomycin-resistant enterococcus (VRE) bacteremia after allogeneic bone marrow transplantation is associated with a rapidly deteriorating clinical course

Abstract

Summary:Vancomycin-resistant enterococcal (VRE) infection is a growing threat. We studied the incidence, risk factors, and clinical course of early-onset VRE bacteremia in allogeneic hematopoietic stem cell transplant recipients. We carried out a chart review of 281 allogeneic hematopoietic stem cell transplant recipients from 1997-2003, including preparative regimen, diagnosis, status of disease, graftversus-host disease prophylaxis, antimicrobial therapy, and survival. VRE bacteremia developed in 12/281 (4.3%) recipients; 10 (3.6%) were within 21 days of transplant. Diagnoses were acute leukemia (7), NHL (2), and MDS (1). In all, 70% had refractory/relapsed disease; 30% were in remission. In total, 50% had circulating blasts. Nine of 10 had matched unrelated donors (7/9 with CD8 þ T-cell depletion). The average time to positive VRE cultures was 15 days; average WBC was 0.05, and 80% had concomitant infections. Despite treatment, all patients died within 73 days of VRE bacteremia. Intraabdominal complications were common. Causes of death included bacterial or fungal infection, multiorgan failure, VOD, ARDS, and relapse. A total of 60% of patients engrafted neutrophils, but none engrafted platelets. Early VRE bacteremia after allogeneic bone marrow transplant is associated with a rapidly deteriorating clinical course, although not always directly due to VRE. Early VRE may be a marker for the critical condition of these high-risk patients at the time of transplant.

Vancomycin-resistant enterococcal bloodstream infections on a hematopoietic stem cell transplant unit: are the sick getting sicker?

“…Avery et al 22 described the outcomes of 12 allogeneic transplant recipients who developed VRE BSI. Ten of 12 patients experienced VRE BSI during the neutropenic period (median 15 days post transplant, range [8][9][10][11][12][13][14][15][16][17][18][19][20][21], and mainly this occurred in patients with refractory or relapsed disease at the time of transplantation (70%).…”

“…[14][15][16][17][18][19][20][21] Although some studies have indicated VRE infections are associated with worse outcomes in immunocompromised patients, 19,20 data on VRE infections in patients with hematologic malignancies and HSCT recipients are limited. 21,22 Therefore we conducted a retrospective cohort study to determine the patient characteristics associated with VRE BSI and risk factors for death in these patients.…”

Should clinicians worry about vancomycin-resistant Enterococcus bloodstream infections?

“…8,9 These infections tend to occur early in the post-transplant period, typically before engraftment. 2 Data on the clinical course of these infections has been conflicting with mortality rates attributed to VRE ranging from B10 10 to 100%. 2 A recent meta-analysis clearly documented that VRE, particularly in immunosuppressed patients, was independently associated with increased mortality among patients with enterococcal bloodstream infections.…”

“…2 Data on the clinical course of these infections has been conflicting with mortality rates attributed to VRE ranging from B10 10 to 100%. 2 A recent meta-analysis clearly documented that VRE, particularly in immunosuppressed patients, was independently associated with increased mortality among patients with enterococcal bloodstream infections. 11,12 Also problematic is the lack of proven, safe and effective regimens in this population to treat VRE infections, which may contribute to a delay in the initiation of appropriate therapy.…”

“…This is a retrospective cohort study of patients with hematologic malignancies and recipients of hematopoietic stem cell transplant (HSCT) who developed nosocomial VRE bloodstream infections (BSIs) over the course of almost 7 years at Barnes-Jewish Hospital. Data regarding VRE infections in this highly immunosuppressed population has been sparse, 1,2 and this paper, reporting the characteristics and outcomes of 60 patients who suffered 68 VRE BSIs, represents the largest published series of VRE BSIs in this population to date. 3 Infections with gram-positive bacteria are a major cause of morbidity in stem cell transplant recipients.…”