Department of Haematology, Christian Medical College and Hospital, Vellore, India.
Microbiology, Christian Medical College and Hospital, Vellore, India.
Transpl Infect Dis. 2020 Jun;22(3):e13273. doi: 10.1111/tid.13273. Epub 2020 Mar 19.
With the increasing incidence of multidrug-resistant (MDR) organisms and high mortality rates associated with these infections, we describe the spectrum of the major drug-resistant pathogens identified in fecal surveillance, and re-visit the use of fecal surveillance in predicting infection with these organisms post-allogeneic stem cell transplant.
Data from allogeneic stem cell transplant recipients with common drug-resistant strains of bacteria in fecal surveillance (Escherichia coli, Klebsiella spp., and Enterococcus spp.) were compared with recipients who did not have the same in fecal surveillance cultures. Baseline characteristics and post-transplant outcomes including similar drug resistance in blood cultures, severe sepsis, and 100-day transplant-related mortality were compared. Multivariate analysis using logistic regression model was used to determine independent predictors of outcome.
In 232 transplants, the prevalence of common drug-resistant isolates in fecal surveillance cultures was 57.7% (134 out of 232 patients-with a single isolate in 115 and ≥2 isolates in the remaining 19 patients. A total of 164 drug-resistant isolates were obtained from 134 patients. Of the 164 isolates, 133 (81%) were positive for ESBL screening, 19 (11.5%) for carbapenem-resistant organisms (CRO) screening, 12 (7.3%) for VRE screening. Patients who had common drug-resistant pathogens detected in fecal surveillance have significantly higher subsequent blood culture positivity with drug resistance, as well as higher 100-day mortality. Factors influencing 100-day mortality included patient's age (P = .001), drug resistance positivity in blood (P < .001), drug resistance in fecal surveillance (P = .011), use of an alternate donor (other than fully matched sibling) (P < .001), GVHD grade 3-4 (P < .001), and severe sepsis (P < .001). On multivariate analysis, only use of an alternate donor (0.024), severe sepsis (P < .001), and grade 3-4 GVHD (P < .001) retained significance in predicting 100-day mortality.
Organisms resistant to 3rd generation cephalosporins are frequently seen on fecal surveillance in the pre-transplant setting and are associated with a higher incidence of drug-resistant organisms in subsequent blood cultures (not limited to the same drug resistance pattern as seen in fecal surveillance). Drug-resistant organisms in fecal surveillance are associated with poorer outcomes following allogeneic stem cell transplant and may be used as a guide to identify patients at risk of subsequently developing a drug-resistant organism in blood.
随着多药耐药（MDR）生物体的发病率不断增加，以及这些感染相关的高死亡率，我们描述了粪便监测中鉴定出的主要耐药病原体的范围，并重新探讨了粪便监测在预测异基因干细胞移植后这些生物体感染中的作用。
对粪便监测中存在常见耐药菌（大肠杆菌、克雷伯菌和肠球菌）的异基因干细胞移植受者的数据与粪便监测培养中未出现相同耐药菌的受者进行了比较。比较了基线特征和移植后结局，包括血液培养中类似的耐药性、严重败血症和 100 天移植相关死亡率。使用逻辑回归模型进行多变量分析，以确定结局的独立预测因素。
在 232 例移植中，粪便监测培养中常见耐药分离株的患病率为 57.7%（134 例患者中有 1 例，其余 19 例患者中有≥2 例分离株）。共有 134 例患者的 164 株耐药分离株。164 株分离株中，133 株（81%）对 ESBL 筛查呈阳性，19 株（11.5%）对碳青霉烯类耐药菌（CRO）筛查呈阳性，12 株（7.3%）对 VRE 筛查呈阳性。在粪便监测中发现常见耐药病原体的患者随后血液培养中具有耐药性的阳性率显著更高，且 100 天死亡率更高。影响 100 天死亡率的因素包括患者年龄（P=0.001）、血液中耐药性阳性（P<0.001）、粪便监测中耐药性（P=0.011）、使用非全匹配供体（而非完全匹配的同胞）（P<0.001）、GVHD 3-4 级（P<0.001）和严重败血症（P<0.001）。多变量分析显示，只有使用非全匹配供体（0.024）、严重败血症（P<0.001）和 3-4 级 GVHD（P<0.001）在预测 100 天死亡率方面具有统计学意义。
在移植前的粪便监测中，经常发现对第三代头孢菌素耐药的生物体，并且与随后血液培养中出现更多耐药生物体有关（不仅限于粪便监测中观察到的相同耐药模式）。粪便监测中的耐药生物体与异基因干细胞移植后不良结局相关，可作为识别随后发生血液耐药生物体风险的患者的指南。
