RESUMEN
BACKGROUND: We aimed to describe the epidemiology, risk factors, and clinical outcomes of co-infections and superinfections in onco-hematological patients with COVID-19. METHODS: International, multicentre cohort study of cancer patients with COVID-19. All patients were included in the analysis of co-infections at diagnosis, while only patients admitted at least 48 h were included in the analysis of superinfections. RESULTS: 684 patients were included (384 with solid tumors and 300 with hematological malignancies). Co-infections and superinfections were documented in 7.8% (54/684) and 19.1% (113/590) of patients, respectively. Lower respiratory tract infections were the most frequent infectious complications, most often caused by Streptococcus pneumoniae and Pseudomonas aeruginosa. Only seven patients developed opportunistic infections. Compared to patients without infectious complications, those with infections had worse outcomes, with high rates of acute respiratory distress syndrome, intensive care unit (ICU) admission, and case-fatality rates. Neutropenia, ICU admission and high levels of C-reactive protein (CRP) were independent risk factors for infections. CONCLUSIONS: Infectious complications in cancer patients with COVID-19 were lower than expected, affecting mainly neutropenic patients with high levels of CRP and/or ICU admission. The rate of opportunistic infections was unexpectedly low. The use of empiric antimicrobials in cancer patients with COVID-19 needs to be optimized.
Asunto(s)
COVID-19 , Coinfección , Neoplasias , Sobreinfección , Estudios de Cohortes , Coinfección/epidemiología , Humanos , Unidades de Cuidados Intensivos , Neoplasias/complicaciones , Neoplasias/epidemiología , SARS-CoV-2RESUMEN
BACKGROUND: Catheter-related bloodstream infection (CRBSI) is one of the most frequent complications in patients with cancer who have central venous catheters (CVCs) implanted and is associated with substantial morbidity and mortality. Taurolidine is a non-antibiotic agent with broad-spectrum antimicrobial activity, which has been used as a lock solution to prevent CRBSI in some settings. However, little is known about its usefulness in high-risk adult neutropenic patients with cancer. This prospective randomised clinical trial aims to test the hypothesis that taurolidine-citrate lock solution is more effective than placebo for preventing catheter infection in neutropenic haematological patients. METHODS: This study is a prospective, multicentre, randomised, double-blinded, parallel, superiority, placebo-controlled trial. Patients with haematological cancer who are expected to develop prolonged neutropenia (> 7 days) and who have a non-tunnelled CVC implanted will be randomised to receive prophylactic taurolidine-citrate-heparin solution using a lock technique (study group) or heparin alone (placebo group). The primary endpoint will be bacterial colonisation of the CVC hubs. The secondary endpoints will be the incidence of CRBSI, CVC removal, adverse events, and 30-day case-fatality rate. DISCUSSION: The lock technique is a preventive strategy that inhibits bacterial colonisation in the catheter hubs, which is the initial step of endoluminal catheter colonisation and the development of infection. Taurolidine is a nontoxic agent that does not develop antibiotic resistance because it acts as an antiseptic rather than an antibiotic. Taurolidine has shown controversial results in the few trials conducted in cancer patients. These studies have important limitations due to the lack of data on adult and/or high-risk neutropenic patients, the type of catheters studied (tunnelled or ports), and the lack of information regarding the intervention (e.g. dwelling of the solution, time, and periodicity of the lock technique). If our hypothesis is proven, the study could provide important solid evidence on the potential usefulness of this preventive procedure in a population at high risk of CRBSI, in whom this complication may significantly impair patient outcome. TRIAL REGISTRATION: ISRCTN, ISRCTN47102251 . Registered on 9 September 2015.
Asunto(s)
Antiinfecciosos/administración & dosificación , Antineoplásicos/efectos adversos , Infecciones Relacionadas con Catéteres/prevención & control , Cateterismo Venoso Central/efectos adversos , Catéteres de Permanencia/efectos adversos , Catéteres Venosos Centrales/efectos adversos , Citratos/administración & dosificación , Neoplasias Hematológicas/tratamiento farmacológico , Neutropenia/inducido químicamente , Taurina/análogos & derivados , Tiadiazinas/administración & dosificación , Antiinfecciosos/efectos adversos , Antineoplásicos/administración & dosificación , Infecciones Relacionadas con Catéteres/diagnóstico , Infecciones Relacionadas con Catéteres/microbiología , Infecciones Relacionadas con Catéteres/mortalidad , Cateterismo Venoso Central/instrumentación , Cateterismo Venoso Central/mortalidad , Citratos/efectos adversos , Remoción de Dispositivos , Método Doble Ciego , Estudios de Equivalencia como Asunto , Neoplasias Hematológicas/mortalidad , Humanos , Estudios Multicéntricos como Asunto , Neutropenia/diagnóstico , Neutropenia/mortalidad , Estudios Prospectivos , Factores de Riesgo , España , Taurina/administración & dosificación , Taurina/efectos adversos , Tiadiazinas/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
Cytomegalovirus (CMV) end-organ disease is a serious, frequent complication after allogenic stem cell transplantation (Allo-SCT). There are two prevention strategies: universal prophylaxis and preemptive therapy. Preemptive therapy is administered based on the results of sensitive techniques that detect the viral infection. We analyzed 41 peripheral blood Allo-SCT recipients: 34 received prophylaxis and seven preemptive treatment. Viral infections determined using real-time polymerase chain reaction (RT-PCR) assays occurred at an overall incidence of 65.8%. The viral loads quantified by RT-PCR were compared among the prophylaxis versus the preemptive group. Overall, the median viral load was significantly higher in the preemptive compared with the prophylaxis group (P=.002). Furthermore, within the first 100 days posttransplantation, viral load values were higher among patients undergoing preemptive therapy (P=.009).
Asunto(s)
Infecciones por Citomegalovirus/prevención & control , Citomegalovirus/fisiología , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa/métodos , Trasplante de Células Madre , Replicación Viral , Citomegalovirus/genética , HumanosRESUMEN
Fifty percent of allogeneic stem cell recipients develop cytomegalovirus (CMV) infection in the first 100 days posttransplantation. Various methods have been used to determine CMV infections, including antigenemia assay and real-time polymerase chain reaction (RT-PCR). Although antigenemia assay has been used more frequently, this technique is less sensitive than RT-PCR. In contrast, RT-PCR has a low positive predictive value for CMV end-organ disease. Cytomegalovirus infections were analyzed in 41 peripheral blood samples from allogeneic stem cell recipients using both antigenemia assay and RT-PCR; results were discordant in 36.6% of patients. Although the antigenemia assay detected CMV replication in 29.2% of cases, RT-PCR was positive in 65.8%. In 83.3% of patients, results detected using the antigenemia assay were delayed by a median (range) of 5 (2-20) weeks compared with positive RT-PCR results. Within the first 100 days posttransplantation, higher levels of viral replication measured using RT-PCR were observed in patients with vs without antigenemia. In addition, in patients with antigenemia, viral load was significantly higher before day 100 than after (P=.01 and P=.008, respectively) compared with those without antigenemia.
Asunto(s)
Antígenos Virales/sangre , Citomegalovirus/fisiología , Reacción en Cadena de la Polimerasa/métodos , Trasplante de Células Madre , Replicación Viral , Citomegalovirus/genética , Citomegalovirus/inmunología , Humanos , Estudios RetrospectivosRESUMEN
Universal empirical antifungal therapy (EAT) in patients with unexplained persistent febrile neutropenia (PFN) is the standard of care, but EAT could be applied in selected patients on the basis of clinical criteria and risk factors. A prospective interventional study was carried out to analyse the incidence and related mortality of invasive fungal infection (IFI) in patients with PFN according to whether or not EAT was indicated. EAT was indicated according to the following criteria: (a) severe sepsis or septic shock; (b) focused infection: lung, central nervous system, sinus, abdominal or skin; (c) individualized clinical decision in patients at high risk. Sixty-six (19%) of 347 episodes of febrile neutropenia fulfilled PFN criteria, 97% with a haematological malignancy. Just 26 (39.4%) were treated with EAT. The overall IFI incidence was 4.5%. In the group that received EAT, three patients developed IFI (11.5%), in comparison with none in the group that did not receive it (P=0.04, RR 2.7:1.9-3.8). IFI-related mortality was null in the group that did not receive EAT and 8% (two of 26 patients) in the group that received EAT. These data suggest that in patients with PFN, EAT in selected patients may be safe and avoid unnecessary antifungal therapy.
Asunto(s)
Antifúngicos/uso terapéutico , Fiebre/tratamiento farmacológico , Micosis/tratamiento farmacológico , Neutropenia/tratamiento farmacológico , Adolescente , Adulto , Antibacterianos/uso terapéutico , Antifúngicos/efectos adversos , Femenino , Fiebre/etiología , Neoplasias Hematológicas/complicaciones , Humanos , Masculino , Micosis/prevención & control , Neutropenia/mortalidad , Estudios Prospectivos , Sepsis/tratamiento farmacológico , Choque Séptico/tratamiento farmacológicoRESUMEN
Cytomegalovirus (CMV) infection causes high morbidity and mortality among allogeneic stem cell transplant recipients. Preemptive therapy with oral valganciclovir or intravenous ganciclovir has replaced universal prophylaxis. We prospectively studied 19 consecutive adult recipients of allogeneic peripheral blood stem cell transplants from May 2005 through February 2007 to analyze the safety and efficacy of preemptive therapy for the treatment of CMV infection. The antigenemia test was persistently negative in 8 patients (42%) and positive at least once in 11 (58%). Eight patients were treated with oral valganciclovir on an outpatient basis and they all became CMV negative after the first week of treatment. The other 3 patients received intravenous ganciclovir and were also CMV negative after the first week of treatment. No patient abandoned treatment, no severe secondary toxicity was noted, and there was no CMV-associated mortality.
Asunto(s)
Antivirales/uso terapéutico , Infecciones por Citomegalovirus/prevención & control , Ganciclovir/análogos & derivados , Ganciclovir/uso terapéutico , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/virología , Trasplante de Células Madre/efectos adversos , Trasplante Homólogo/efectos adversos , Administración Oral , Adolescente , Adulto , Antivirales/administración & dosificación , Ganciclovir/administración & dosificación , Enfermedad de Hodgkin/cirugía , Humanos , Inyecciones Intravenosas , Leucemia/cirugía , Persona de Mediana Edad , Síndromes Mielodisplásicos/cirugía , Estudios Prospectivos , Valganciclovir , Adulto JovenRESUMEN
El diagnóstico de enfermedad por citomegalovirus (CMV) en el paciente con infección por VIH no resulta con frecuencia fácil y suele aparecer en el contexto de inmunosupresión severa por reactivación o reinfección del virus. Además, aunque tras la introducción de terapia antirretroviral de gran actividad (TARGA) la incidencia de enfermedad por CMV ha disminuido de forma drástica, es una entidad a tener en cuenta con considerable morbimortalidad. Presentamos el caso de un paciente con fiebre infiltrados pulmonares y dolor abdominal tras la resolución de una neumonía por P.jirovecii con aislamiento de CMV (shellvial positivo) en LBA y biopsia gástrica. Se plantea el posible diagnóstico de enfermedad digestiva y pulmonar por CMV iniciando tratamiento dirigido con respuesta clínica. En este paciente llama la atención la rápida progresión a SIDA desde el diagnóstico y resulta sugerente la hipótesis de que una confección simultánea de VIH y CMV fuese la responsable del rápido deterioro inmunológico (AU)
In HIV-infected patients, cytomegalovirus (CMV) disease diagnosis is usually difficult and disease results from reactivation of latent infection or reinfection in the context of severe immunosuppression. Although the introduction of highly active antiretroviral therapy (HAART) has resulted in an important decline of CMV disease, it has considerable morbidity and mortality rate. We present a case of a patient who presented fever, pulmonary infiltrates and abdominal pain after P.jirovecii pneumonia, with isolated of CMV (positive shell-vial) from LBA and gastric biopsy. We propose a possible diagnosis of digestive and pulmonary CMV disease and we initiated treatment for this with clinical response. It results surprising the rapid progression to SIDA of the patient and we can suggest that a co-infection HIV-CMV could be the cause for the rapid immunological damage (AU)
Asunto(s)
Humanos , Masculino , Adulto , Neumonía por Pneumocystis/diagnóstico , Infecciones Oportunistas Relacionadas con el SIDA/diagnóstico , Pneumocystis carinii/patogenicidad , Neumonía por Pneumocystis/tratamiento farmacológico , Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Ensayo de Inmunoadsorción Enzimática , Terapia Antirretroviral Altamente Activa , Pneumocystis cariniiRESUMEN
The aim of the present study is to evaluate the epidemiology, etiology and prognosis of pneumonia in lung transplant (LT) recipients. This is a prospective, multicenter study of a consecutive cohort of LT recipients in Spain. From September 2003 to November 2005, 85 episodes of pneumonia in 236 LT recipients were included (incidence 72 episodes per 100 LT/year). Bacterial pneumonia (82.7%) was more frequent than fungal (14%) and viral pneumonia (10.4%). The most frequent microorganisms in each etiological group were Pseudomonas aeruginosa (n = 14, 24.6%), CMV (n = 6, 10.4%) and Aspergillus spp. (n = 5, 8.8%). Incidence of Aspergillus spp. and CMV pneumonia is lower than previously reported, probably due to the spread of universal prophylaxis. Pneumonia caused by viruses appeared significantly later than pneumonia due to gram-negative bacilli, fungi and those without known etiology (p < 0.01, p = 0.03 and p = 0.02, respectively). The routine use of ganciclovir has changed the natural history of CMV infection, so that pneumonia appears later, once prophylaxis is suspended. The probability of survival during the first year of follow-up was significantly higher in the multivariate analysis in LT recipients who did not have a pneumonia episode compared with those that had at least one episode (p < 0.01).
Asunto(s)
Trasplante de Pulmón , Neumonía , Factores de Edad , Antiinfecciosos/uso terapéutico , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Neumonía/epidemiología , Neumonía/etiología , Neumonía/prevención & control , Complicaciones Posoperatorias , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Distribución por Sexo , España/epidemiología , Tasa de SupervivenciaRESUMEN
In HIV-infected patients, cytomegalovirus (CMV) disease diagnosis is usually difficult and disease results from reactivation of latent infection or reinfection in the context of severe immunosupression. Although the introduction of highly active antiretroviral therapy (HAART) has resulted in a important decline of CMV disease, it has considerable morbidity and mortality rate. We present a case of a patient who presented fever, pulmonary infiltrates and abdominal pain after P.jirovecii pneumonia, with isolated of CMV (positive shell-vial) from LBA and gastric biopsy. We propose a possible diagnosis of digestive and pulmonary CMV disease and we initiated treatment for this with clinical response. It results surprising the rapid progression to SIDA of the patient and we can suggest that a co-infection HIV-CMV could be the cause for the rapid immunological damage.