Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Antibiotic Stewardship, Seattle Cancer Care Alliance, Seattle, Washington.
Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
Biol Blood Marrow Transplant. 2019 Jun;25(6):1247-1252. doi: 10.1016/j.bbmt.2019.01.031. Epub 2019 Feb 1.
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.
用于治疗急性移植物抗宿主病（GVHD）的类固醇被认为会减轻感染的临床症状。我们旨在评估每周从接受大剂量类固醇治疗的造血细胞移植（HCT）患者的门诊采集的监测血培养（SBC）的价值。我们假设大多数门诊监测培养物将是低致病性、革兰阳性菌，并且会导致过度使用万古霉素治疗。我们对 2009 年 4 月至 2013 年 5 月期间参加高剂量类固醇（泼尼松等效剂量≥0.5mg/kg/天）治疗急性 GVHD 临床试验的成年 HCT 患者队列的血培养进行了回顾性分析。SBC 被定义为在接受大剂量类固醇治疗的同时，从门诊中央静脉导管中每周采集的血培养。排除作为症状检查或作为已记录菌血症的随访获得的培养物。使用中心数据库收集临床数据，并通过病历回顾进行补充。共有 127 名 HCT 受者符合纳入本研究的条件。共获得 1015 份 SBC，每位患者中位数为 8 份培养物（四分位间距，5 至 10）。在 30 名独特的患者中，从 1015 份培养物中的 36 份（3.5%）中分离出 42 种生物体，即每 28 份血培养物中就有 1 份阳性培养物。最常检测到的生物体是凝固酶阴性葡萄球菌（25/1015[2.5%]）。革兰氏阴性菌很少见（4/1015[0.4%]）。大多数接受阳性监测培养物的患者都接受了抗生素治疗（36/36[92%]）。有 6 人因治疗入院；没有需要重症监护或死于菌血症。万古霉素是最常使用的抗生素，占队列中 376 天抗生素总天数（256/376）的 68%，中位持续时间为 10 天（四分位间距，7 至 14）。每周从接受大剂量糖皮质激素治疗异基因 HCT 后急性 GVHD 的无症状患者中采集的门诊 SBC 很少呈阳性，并且大多数生物体都是低致病性生物体。SBC 还导致抗生素暴露和费用增加，这表明这种门诊筛查的好处在这种情况下可能价值有限。
