Prophylactic Trimethoprim-Sulfamethoxazole for Allogeneic Hematopoietic Stem Cell Transplant Recipients During the Pre-engraftment Period.

BACKGROUND: Our institution has used trimethoprim-sulfamethoxazole (TMP-SMX) as the antibacterial agent of choice for infection prophylaxis during the pre-engraftment period in the allogeneic transplant (allo-HCT) population. METHODS: This retrospective, single center study was developed to compare the safety of that antibacterial prophylaxis to fluoroquinolones in allo-HCT. The primary endpoint was time to neutrophil engraftment. RESULTS: A total of 366 patients were reviewed (TMP-SMX n = 332, fluoroquinolone n = 34). No difference in days to neutrophil engraftment was found (median 15 versus 16 days, p = 0.62). Hyperkalemia was more common in the TMP-SMX cohort (32.2% versus 14.7%, p = 0.035); this did not contribute to a higher rate of agent discontinuation or arrhythmia. There was no significant difference in the incidence of neutropenic fever; however, those in the TMP-SMX cohort were more likely to have microbiologically confirmed bacteremia (24.1% versus 8.8% respectively, p = 0.043). There was no significant difference in infections. No long-term implication of prophylactic antibacterial agent selection was observed in terms of graft-versus-host-disease, underlying disease relapse, or mortality. CONCLUSION: The use of TMP-SMX was associated with a higher likelihood of bacteremia and hyperkalemia; however, this did not result in increased hospital stay, escalation of care, or mortality. The use of TMP-SMX for prophylaxis during the pre-engraftment period for allo-HCT recipients is safe and effective.

Severity of acute gastrointestinal graft-vs-host disease is associated with incidence of bloodstream infection after adult allogeneic hematopoietic stem cell transplantation.

BACKGROUND: Infections are the most common cause of non-relapse mortality in adult allogeneic hematopoietic stem cell transplant (allo HSCT) recipients. Acute gastrointestinal graft-vs-host disease (GI GVHD) often leads to friable mucosa as well as treatment interventions which can increase risk of infection. Our primary objective was to describe the relationship between increasing grades of acute GI GVHD and incidence of bloodstream infections (BSI). METHODS: We reviewed 441 adults who underwent allo HSCT from 2011 to 2017 and were clinically diagnosed with GI GVHD, non-GI GVHD, or no GVHD based on the modified Glucksberg scale within the first 100 days of transplantation. The maximum grades of acute GI GVHD and non-GI GVHD were used in the analysis. BSI was defined based on the presence of a blood culture positive for bacteria or fungi and treatment with antibiotics. The incidence of BSI within the first 180 days of transplantation was estimated with the cumulative incidence method. Fine and Gray regression was used to assess association between clinical grade of acute GI GVHD and BSI risk, adjusting for grade of non-GI GVHD and for other significant baseline patient risk factors for BSI identified by multivariable analysis. Results are shown as hazard ratio (HR) and 95% confidence interval (CI). A similar analysis was conducted in 130 patients with histologic grade of acute GI GVHD. RESULTS: Overall BSI incidence by day 180 was 32%; gram-negative bacilli were the predominant organisms, followed by gram-positive cocci and fungi. Patients with grade 4 acute GI GVHD had higher risk of BSI as compared to patients with no GI GVHD (HR 2.98, CI 1.65-5.37, P < .001), while those with grade 3 acute GI GVHD had similar BSI risk (HR 0.89, CI 0.36-2.21, P = .81). Grade of GI GVHD had no association with risk of non-BSI. Results were similar in patients with histologic grade acute GI GVHD. Patients who developed BSI or non-BSI had significantly higher overall mortality risk compared to those without infectious complications (HR 2.52, CI 1.92-3.31, P < .001 for BSI; HR 1.60, CI 1.20-2.13, P = .001 for non-BSI). CONCLUSIONS: Grade 4 acute GI GVHD is associated with a higher risk of BSI, which is in turn associated with a higher risk of overall mortality in this population. Understanding the relationships between acute GI GVHD, BSI, and overall mortality can guide future treatment strategies for adult allo HSCT recipients.

Influenza update 2018-2019: 100 years after the great pandemic.

Four influenza pandemics, starting with the historic 1918 pandemic, have killed thousands of people around the world. Vaccination, still the most important means of preventing influenza, is currently recommended yearly for all people age 6 months and older, with a goal of vaccinating 80% of all Americans and 90% of at-risk populations. Neuraminidase inhibitors are underused, and a new drug with a different mechanism of action, baloxavir marboxil, is expected to be approved soon in the United States.

Primary Cytomegalovirus Syndrome: An Unexpected Cause of Donor Morbidity Shortly After Right Lobectomy for Living-Donor Liver Transplant.

We present a case of initially unexplained fever in a living right liver lobe transplant donor that turned out to be due to primary cytomegalovirus infection.

Influenza: Still more important than Zika virus in 2016-2017.

Influenza kills and hospitalizes many people every year. Although the 2015-2016 influenza season was relatively mild, we should remain vigilant in our efforts to reduce the impact of future epidemics or pandemics by implementing universal influenza vaccination and early initiation of antiviral therapy for suspected cases. We don't expect influenza vaccine to prevent all cases of influenza, since immune response varies depending on age, underlying diseases, and immunosuppression.

2012-2013 influenza update: hitting a rapidly moving target.

From the deadly 2009 influenza A H1N1 pandemic to the looming threat of bird flu H5N1, the recent outbreak of swine flu H3N2v at agriculture fairs, and the emergence of drug-resistant H1N1, we are constantly challenged by influenza viruses. Vaccination remains the main strategy for prevention. With the knowledge gained from past pandemics, an adequate vaccine supply, and an updated preventive strategy, we are in a better position to face the challenge.

The resurgence of swine-origin influenza A (H1N1).

Unexpectedly, swine-origin influenza A (H1N1) virus (S-OIV, informally known as swine flu) appeared in North America at the very end of the 2008-2009 influenza season and began to spread internationally. As the world mobilizes for a potential pandemic, this article summarizes the developments in diagnosis, treatment, and prevention.