Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, Milan, Italy.
Infectious Disease Unit, IRCCS San Raffaele Hospital, Milan, Italy.
Biol Blood Marrow Transplant. 2018 Jul;24(7):1476-1482. doi: 10.1016/j.bbmt.2018.02.021. Epub 2018 Mar 2.
Multidrug-resistant Gram-negative bacteria (MDR-GNB) are an emerging cause of morbidity and mortality after hematopoietic stem cell transplantation (HSCT). Three-hundred forty-eight consecutive patients transplanted at our hospital from July 2012 to January 2016 were screened for a pretransplant MDR-GNB colonization and evaluated for clinical outcomes. A pretransplant MDR-GNB colonization was found in 16.9% of allo-HSCT and in 9.6% of auto-HSCT recipients. Both in auto- and in allo-HSCT, carriers of a MDR-GNB showed no significant differences in overall survival (OS), transplant-related mortality (TRM), or infection-related mortality (IRM) compared with noncarriers. OS at 2 years for carriers compared with noncarriers was 85% versus 81% (P = .262) in auto-HSCT and 50% versus 43% (P = .091) in allo-HSCT. TRM at 2 years was 14% versus 5% (P = .405) in auto-HSCT and 31% versus 25% (P = .301) in allo-HSCT. IRM at 2 years was 14% versus 2% (P = .142) in auto-HSCT and 23% versus 14% (P = .304) in allo-HSCT. In multivariate analysis, only grade III to IV acute graft-versus-host disease was an independent factor for reduced OS (P < .001) and increased TRM (P < .001) and IRM (P < .001). During the first year after transplant, we collected 73 GNB bloodstream infectious (BSI) episodes in 54 patients, 42.4% of which sustained by a MDR-GNB. Rectal swabs positivity associated with the pathogen causing subsequent MDR-GNB BSI episodes in 13 of 31 (41.9%). Overall, OS at 4 months from MDR-GNB BSI episode onset was of 67.9%, with a 14-day attributed mortality of 12.9%, not being significantly different between carriers and noncarriers (P = .207). We conclude that in this extended single-center experience, a pretransplant MDR-GNB colonization did not significantly influence OS, TRM, and IRM both in auto- and allo-HSCT settings and that MDR-GNB attributed mortality can be controlled in carriers when an early pre-emptive antimicrobial therapy is started in case of neutropenic fever.
多药耐药革兰氏阴性菌（MDR-GNB）是造血干细胞移植（HSCT）后发病率和死亡率上升的一个新兴原因。我们医院从 2012 年 7 月至 2016 年 1 月连续筛查了 348 例接受移植的患者，以筛查移植前 MDR-GNB 定植情况，并评估临床结局。在 16.9%的异基因 HSCT 和 9.6%的自体 HSCT 受者中发现移植前 MDR-GNB 定植。在自体和异基因 HSCT 中，MDR-GNB 携带者的总生存率（OS）、移植相关死亡率（TRM）和感染相关死亡率（IRM）与非携带者相比均无显著差异。与非携带者相比，携带者的 2 年 OS 为 85%对 81%（P=0.262），在自体 HSCT 中为 50%对 43%（P=0.091）。2 年时的 TRM 为 14%对 5%（P=0.405），在自体 HSCT 中为 31%对 25%（P=0.301）。2 年时的 IRM 为 14%对 2%（P=0.142），在自体 HSCT 中为 23%对 14%（P=0.304）。在多变量分析中，只有 3 级至 4 级急性移植物抗宿主病是降低 OS（P<0.001）和增加 TRM（P<0.001）和 IRM（P<0.001）的独立因素。移植后第一年，我们在 54 名患者中收集了 73 例革兰氏阴性菌血流感染（BSI）发作，其中 42.4%由 MDR-GNB 引起。直肠拭子阳性与随后的 MDR-GNB BSI 发作中病原体有关，在 31 例中占 13 例（41.9%）。总体而言，从 MDR-GNB BSI 发作开始的 4 个月时的 OS 为 67.9%，14 天归因死亡率为 12.9%，携带者和非携带者之间无显著差异（P=0.207）。我们得出结论，在这项扩展的单中心经验中，移植前 MDR-GNB 定植在自体和异基因 HSCT 环境中均未显著影响 OS、TRM 和 IRM，并且在发生中性粒细胞减少性发热时，如果开始早期先发制人的抗菌治疗，可以控制 MDR-GNB 归因死亡率在携带者中。
