Infectious Disease Department, Hospital Clinic-IDIBAPS, Barcelona, Spain.
Infectious Disease Department, Hospital Clinic-IDIBAPS, Barcelona, Spain.
Transplant Cell Ther. 2021 Jun;27(6):501.e1-501.e6. doi: 10.1016/j.jtct.2021.03.017. Epub 2021 Mar 23.
In recent years, important epidemiologic changes have been described in hematopoietic stem cell transplantation (HSCT) recipients with bloodstream infection (BSI), with increases in gram-negative bacilli and multidrug resistant (MDR) gram-negative bacilli. These changes have been linked to a worrisome increase in mortality. We aimed to define the risk factors for mortality of HSCT patients experiencing BSI. All episodes of BSI in patients with HSCT between 2008 and 2017 were prospectively collected. Multivariate analyses were performed. A total of 402 BSI episodes were documented in 293 patients who had undergone HSCT (75.4% allogenic, 32.3% autologous, 19.3% second HSCT). The median time from HSCT to BSI was 62 days (interquartile range, 9 to 182 days). Gram-positive cocci accounted for 56.7% of the episodes; gram-negative bacilli, for 42%. The most common microorganisms were coagulase-negative staphylococci (30.6%) and Pseudomonas aeruginosa (15.9%). MDR gram-negative bacilli caused 11.9% of all episodes. Clinical characteristics, source of BSI, etiology, and outcomes changed depending on time since HSCT. Globally, 26.6% of episodes were treated with inappropriate empiric antibiotic therapy, more frequently in BSI episodes caused by P. aeruginosa, MDR P. aeruginosa, and MDR gram-negative bacilli. The 30-day mortality was 19.2%. Independent risk factors for mortality were BSI occurring ≥30 days after HSCT (odds ratio [OR], 11.21; 95% confidence interval [CI], 4.63 to 27.19), shock (OR, 7.10; 95% CI, 2.98 to 16.94), BSI caused by MDR P. aeruginosa (OR, 4.45; 95% CI, 1.12 to 17.72), and inappropriate empiric antibiotic therapy for gram-negative bacilli or Candida spp. (OR, 3.73; 95% CI, 1.27 to 10.89). HSCT recipients experiencing BSI have high mortality related to host and procedure factors, causative microorganism, and empiric antibiotic therapy. Strategies to identify HSCT recipients at risk of MDR P. aeruginosa and reducing inappropriate empiric antibiotic therapy are paramount to reduce mortality.
近年来，造血干细胞移植（HSCT）患者血流感染（BSI）的重要流行病学变化已经得到描述，革兰氏阴性杆菌和多重耐药（MDR）革兰氏阴性杆菌的数量有所增加。这些变化与死亡率的令人担忧的增加有关。我们旨在确定 HSCT 患者发生 BSI 的死亡风险因素。前瞻性收集了 2008 年至 2017 年间接受 HSCT 的患者的所有 BSI 发作。进行了多变量分析。在接受 HSCT 的 293 名患者中记录了 402 次 BSI 发作（异基因 75.4%，自体 32.3%，第二次 HSCT 19.3%）。从 HSCT 到 BSI 的中位时间为 62 天（四分位距，9-182 天）。革兰氏阳性球菌占发作的 56.7%；革兰氏阴性杆菌占 42%。最常见的微生物是凝固酶阴性葡萄球菌（30.6%）和铜绿假单胞菌（15.9%）。MDR 革兰氏阴性杆菌引起了 11.9%的所有发作。临床特征、BSI 来源、病因和结局随 HSCT 后时间的变化而变化。总体而言，26.6%的发作接受了不适当的经验性抗生素治疗，铜绿假单胞菌、MDR 铜绿假单胞菌和 MDR 革兰氏阴性杆菌引起的 BSI 发作中更常见。30 天死亡率为 19.2%。死亡的独立危险因素是 HSCT 后≥30 天发生的 BSI（比值比[OR]，11.21；95%置信区间[CI]，4.63 至 27.19）、休克（OR，7.10；95%CI，2.98 至 16.94）、MDR 铜绿假单胞菌引起的 BSI（OR，4.45；95%CI，1.12 至 17.72）以及革兰氏阴性杆菌或念珠菌属的不适当经验性抗生素治疗（OR，3.73；95%CI，1.27 至 10.89）。发生 BSI 的 HSCT 受者的死亡率高与宿主和手术因素、致病微生物和经验性抗生素治疗有关。确定 MDR 铜绿假单胞菌高危 HSCT 受者并减少不适当经验性抗生素治疗的策略对于降低死亡率至关重要。
