Limited Utility of Outpatient Surveillance Blood Cultures in Hematopoietic Cell Transplant Recipients on High-Dose Steroids for Treatment of Acute Graft-versus-Host-Disease

Abstract

Steroids used to treat acute graft-versus-host-disease (GVHD) are believed to blunt clinical symptoms of infection. We aimed to assess the value of weekly surveillance blood cultures (SBCs) drawn in an outpatient setting from hematopoietic cell transplant (HCT) patients receiving high-dose steroids. We hypothesized that most positive outpatient surveillance cultures would be low-pathogenicity, gram-positive organisms and would lead to excess vancomycin therapy. We conducted a retrospective review of blood cultures collected from a cohort of adult HCT patients enrolled in a clinical trial of acute GVHD therapy with high-dose steroids (prednisone-equivalent doses .5 mg/kg/day) between April 2009 and May 2013. SBCs were defined as those collected weekly from central venous catheters in the outpatient setting while patients were receiving high-dose steroids. Cultures obtained as part of a symptom workup or as follow-up for documented bacteremia were excluded. Clinical data were collected using center databases supplemented by medical record review. One hundred twenty-seven HCT recipients were eligible for inclusion in the study. A total of 1015 SBCs were obtained, with a median of 8 cultures (interquartile range, 5 to 10) per patient. Forty-two organisms were isolated from 36 of 1015 cultures (3.5%) in 30 unique patients, or 1 positive culture per 28 blood cultures drawn. The most frequently detected organisms were coagulase-negative Staphylococci (25/1015 [2.5%]). Gram-negative organisms were rare (4/1015 [.4%]. Antibiotics were administered to most patients with positive surveillance cultures (33/36 [92%]). Six were admitted to the hospital for treatment; none needed intensive care or died from their bacteremia. Vancomycin was the most frequently administered antibiotic, comprising 256 of 376 total days (68%) of antibiotic received by the cohort with a median duration of 10 days ((interquartile range, 7 to 14). Weekly outpatient SBCs obtained from asymptomatic patients on high-dose glucocorticoids for treatment of acute GVHD after allogeneic HCT were infrequently positive, and most organisms were low-pathogenicity organisms. SBCs also led to excess antibiotic exposure and costs, suggesting benefits of such ambulatory screening may be of limited value in this setting.

Predictive Value of 3 Clinical Criteria for Sepsis (Quick Sequential Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and National Early Warning Score) With Respect to Short-term Mortality in Allogeneic Hematopoietic Cell Transplant Recipients With Suspected Infections

“…Surveillance blood cultures were routinely drawn per protocol from patients treated with high-dose glucocorticoids (> 0.5 mg/kg). These surveillance cultures were drawn biweekly while inpatient, weekly on outpatient discharge, and were discontinued following tapering of glucocorticoids to < 0.5 mg/kg [ 23 ]. Most blood cultures were drawn through central venous catheters.…”

Central venous catheter–related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

“…Screening for CRIs in asymptomatic patients by routine withdrawal of blood cultures is not recommended, as weekly or even daily blood culturing is not effective in the earlier detection of CRI in cancer patients including HSCT recipients [114][115][116][117].…”

Changing the culture of blood cultures: Opportunities for diagnostic stewardship in febrile neutropenia

“…However, this population has much to gain from diagnostic stewardship: reduced phlebotomy in patients who need frequent transfusions, less frequent detection of blood culture contaminants, improved antimicrobial use, and more accurate diagnosis of hospital-associated infections. [1][2][3][4][5] Ultimately, the balance between early detection of an infectious pathogen and avoidance of over-testing remains elusive in febrile neutropenia diagnostic investigations.…”

“…Though there are limited studies evaluating the impact of diagnostic stewardship in immunocompromised patients -including those with hematologic malignancies and recipients of solid organ transplants, hematopoietic cell transplants (HCT), or other cellular therapies -there is a growing body of literature suggesting that diagnostic stewardship can be feasible, safe, and effective even in this population who is at high risk for serious infections. [4][5][6] Several diagnostic stewardship opportunities that have been proposed for transplant recipients include appropriate stool testing for Clostridioides difficile infections, judicious use of urine cultures to reduce treatment of asymptomatic bacteriuria, targeted diagnostic testing of respiratory samples and limiting the use of surveillance blood cultures. 5,6 Febrile neutropenia, a common complication in patients with hematologic malignancies and HCT recipients, involves high utilization of diagnostic tests and presents unique diagnostic stewardship opportunities.…”