A pragmatic multi-institutional approach to understanding transplant-associated thrombotic microangiopathy after stem cell transplant.

Transplant-associated thrombotic microangiopathy (TA-TMA) is a severe complication of hematopoietic stem cell transplantation (HSCT). A single-center prospective screening study has shown that the incidence of TA-TMA is much higher than prior retrospective studies that did not systematically screen. These data have not been replicated in a multicenter study. Our objective was to determine the incidence and risk factors for TA-TMA and compare outcomes of pediatric HSCT patients with and without TA-TMA. Patients were prospectively screened for TA-TMA at participating centers using a simple to implement and inexpensive strategy from the start of the preparative regimen through day +100. TA-TMA was diagnosed if ≥4 of 7 laboratory/clinical markers diagnostic for TA-TMA were present concurrently or if tissue histology showed TA-TMA. A total of 614 patients (359 males; 58%) received prospective TA-TMA screening at 13 pediatric centers. TA-TMA was diagnosed in 98 patients (16%) at a median of 22 days (interquartile range, 14-44) posttransplant. Patients with TA-TMA had significantly increased bloodstream infections (38% [37/98] vs 21% [107/51], P ≤ .001), mean total hospitalization days (68; 95% confidence interval [CI], 63-74 vs 43; 95% CI, 41-45; P ≤ .001), and number of days spent in the intensive care unit (10.1; 95% CI, 6.4-14; vs 1.6; 95% CI, 1.1-2.2; P ≤ .001) in the first 100 days after HSCT compared with patients without TA-TMA. Overall survival was significantly higher in patients without TA-TMA (93%; 490/516) compared with patients with TA-TMA (78%; 76/98) (P ≤ .001). These data support the need for systematic screening for TA-TMA and demonstrate the feasibility and efficacy of an easy to implement strategy to do so.

Outcomes after bloodstream infection in hospitalized pediatric hematology/oncology and stem cell transplant patients.

BACKGROUND: Pediatric hematology/oncology (PHO) patients receiving therapy or undergoing hematopoietic stem cell transplantation (HSCT) often require a central line and are at risk for bloodstream infections (BSI). There are limited data describing outcomes of BSI in PHO and HSCT patients. METHODS: This is a multicenter (n = 17) retrospective analysis of outcomes of patients who developed a BSI. Centers involved participated in a quality improvement collaborative referred to as the Childhood Cancer and Blood Disorder Network within the Children's Hospital Association. The main outcome measures were all-cause mortality at 3, 10, and 30 days after positive culture date; transfer to the intensive care unit (ICU) within 48 hours of positive culture; and central line removal within seven days of the positive blood culture. RESULTS: Nine hundred fifty-seven BSI were included in the analysis. Three hundred fifty-four BSI (37%) were associated with at least one adverse outcome. All-cause mortality was 1% (n = 9), 3% (n = 26), and 6% (n = 57) at 3, 10, and 30 days after BSI, respectively. In the 165 BSI (17%) associated with admission to the ICU, the median ICU stay was four days (IQR 2-10). Twenty-one percent of all infections (n = 203) were associated with central line removal within seven days of positive blood culture. CONCLUSIONS: BSI in PHO and HSCT patients are associated with adverse outcomes. These data will assist in defining the impact of BSI in this population and demonstrate the need for quality improvement and research efforts to decrease them.

Feasibility of continuous temperature monitoring in pediatric immunocompromised patients: A pilot study.

Early recognition of fever is paramount in reducing morbidity and mortality in immunocompromised patients. We performed a pilot study to determine the feasibility, safety, and tolerability of continuous temperature monitoring via TempTraq, a continuous temperature monitoring patch. Ten pediatric patients were enrolled and received continuous temperature monitoring over 5 days in addition to episodic monitor (standard of care). Episodic monitoring failed to detect fever in two patients and there was a significant delay (>12 h) of fever detection in two others that was detected with TempTraq. Additionally, caregivers reported TempTraq was tolerable and easy to apply.

Comparing a Neutropenic Diet to a Food Safety-Based Diet in Pediatric Patients Undergoing Hematopoietic Stem Cell Transplantation.

Neutropenic diets were adopted as a way to decrease the infection risks in immunocompromised individuals, but these diets result in significant restrictions in the variety and types of foods an individual may consume. We used a controlled before-and-after study design in consecutive pediatric and young adult patients who underwent hematopoietic stem cell transplant at our center between January 1, 2014, and December 31, 2014. From January through June, all patients were placed on a traditional neutropenic diet; on July 1, we liberalized the bone marrow transplant (BMT) diet to a modified BMT diet. We compared the incidence of bloodstream infections in the first 100 days post-transplant, incidence of norovirus in the first 100 days, total parenteral nutrition days through day 100, incidence of grade 3 to 4 graft-versus-host disease at day 100, gastrointestinal graft-versus-host disease (any stage), and 100-day overall survival. In addition, we administered an investigator-created survey to evaluate food cravings, nausea, diet limitations, and subjective quality of life. In total, 102 patients underwent hematopoietic stem cell transplant during the study period. Forty-nine (48%) received the neutropenic diet and 53 (52%) the BMT diet. Other than more males receiving the neutropenic diet (67% versus 47%, P = 0.05), there were no statistical demographic and outcome differences between the 2 groups. Additionally, 46 subjects (45%) completed the investigator-created questionnaire. There was no difference in the perceived food cravings, nausea, diet limitations, and subjective quality of life between the 2 cohorts. These data demonstrate noninferiority of the modified BMT diet over the traditional neutropenic diet. We believe the food safety-based diet offers a greater variety of food, which may assist in the transition to a normal diet.

Multiple bloodstream infections in pediatric stem cell transplant recipients: A case series.

Bacterial bloodstream infections (BSIs) are associated with poor outcomes following stem cell transplantation (SCT). We describe the demographics, treatment, complications, and outcome of 23 pediatric SCT recipients who developed three or more BSIs in the first year after SCT at our center from 2011 through 2016. The majority underwent allogeneic SCT (n = 22/23;96%), mainly from an unrelated donor (n = 19/22,86%); developed grade 2-4 graft versus host disease (GVHD; n = 14/23, 61%), all steroid refractory; and were diagnosed with thrombotic microangiopathy (n = 21/23, 91%). One-year overall survival was 56% (n = 13/23). We observed a high rate of transplant-associated thrombotic microangiopathy and steroid-refractory acute GVHD in patients with three or more BSIs.

Sleep disruption in caregivers of pediatric stem cell recipients.

Parents/caregivers of hospitalized patients are at risk of sleep disruption. We performed a cross-sectional quantitative and qualitative evaluation of sleep in parents/caregivers of children undergoing hematopoietic stem cell transplant (HSCT; n = 17). Additionally, we explored the frequency of room entries for hospitalized patients undergoing HSCT (n = 189 nights). Twelve caregivers (71%) demonstrated significant sleep disturbance, 12 (71%) described sleep quality as poor, 15 (88%) averaged < 6 hours of sleep per night, 14 (82%) awakened at least four times per night. Patient rooms were entered a median of 12 times per night (interquartile range 10-15). Intervention studies to improve caregiver sleep during hospitalization are needed.