Unique risk factors for bacteraemia in allogeneic bone marrow transplant recipients before and after engraftment

Abstract

Summary:A study of the risk factors associated with bacteraemia in 191 allogeneic bone marrow transplant (BMT) recipients (1991-1996) was performed. In contrast to risk factors commonly cited for cancer chemotherapy, mucositis, degree of conditioning toxicity of the gut and lungs, duration of neutropenia, and severity of neutropenia and monocytopenia were not associated with bacteraemia in the pre-engraftment period, during which the only significant risk factor was late stage underlying disease (P Ͻ 0.05). After engraftment, Hickman catheter infection, and severe acute and chronic graft-versushost disease (GVHD) were found to be independently associated with bacteraemia by multivariate analysis (P Ͻ 0.001, Ͻ0.05 and Ͻ0.05, respectively). This might be explained by intense antimicrobial prophylaxis, early empirical treatment, and non-routine use of haemopoietic growth factors. No significant difference in mortality was detected between bacteraemic and non-bacteraemic patients in both periods. Allogeneic BMT recipients are therefore a group of patients distinct from other cancer patients receiving chemotherapy at risk of developing bacteraemia. The study findings prompt consideration of a management protocol incorporating early and routine use of haemopoietic growth factors before engraftment in high-risk patients with late stage underlying malignancies, routine antimicrobial prophylaxis for acute GVHD with intense immunosuppression, and intravenous immunoglobulin therapy for chronic GVHD. Further cost-benefit analyses are warranted.

Blood stream infection after hematopoietic stem cell transplantation is associated with increased mortality

“…This finding has not been consistent in the literature. 9,16 However, our observation is noted for all BSI, or BSI further categorized as due to GNR, BSI with organisms other than GNR or BSI with VRE. The contribution of BSI to mortality after HSCT is more striking when considering that (1) the observation remains even when adjusting for the presence of acute GVHD, a major cause of morbidity and mortality after HSCT and (2) the risk persisted throughout the entire post-HSCT period studied.…”

“…These include age greater than 18 years, underlying disease, late stage of underlying disease, the presence of a Hickman catheter infection, severe graft-versus-host disease (GVHD), mucositis and steroid use. 4,10,[15][16][17][18][19] However, not all studies are in agreement.…”

“…6 Other observers have demonstrated no difference in mortality between those HSCT recipients with and without BSI. 9,16 Death associated with BSI was rare in several series of BSI in allogeneic HSCT recipients unless the offending organisms were Gram-negative bacilli (GNR). In this circumstance, the crude mortality rates were 24-40%.…”

Etiology, clinical features and outcomes of pre-engraftment and post-engraftment bloodstream infection in hematopoietic SCT recipients

“…Both acute and chronic GVHD are known risk factors for BSI in allogeneic transplant recipients. 6,9,23 GVHD may cause profound immunodeficiency with B-and T-cell depletion, impairment of lymphocyte function and neutropenia. 24 Patients with GHVD have also been found to have suboptimal serum opsonizing activity due to the associated hypogammaglobulinemia.…”

“…Nevertheless, the differences between infections occurring pre-and post-engraftment have not been fully described. 2,6 Most published articles regarding BSI in HSCT recipients are retrospective and/or focus on subjects who underwent transplantation in the 1990 s. 3,[5][6][7][8][9][10] Since then, there have been changes in the care of HSCT recipients, such as the introduction of different types of donors, different immunosuppression, conditioning chemotherapy including reduced-intensity regimens, and so on. Furthermore, changes in the etiology of BSI in cancer patients have recently been described.…”