bacterial infections in hsct - european society for blood ... filebacterial infections in hsct...
TRANSCRIPT
![Page 1: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/1.jpg)
Bacterial infections in HSCT
Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa
Hospital Clinic, Barcelona, Spain
Vienna. 8-10 May, 2014
![Page 2: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/2.jpg)
1 3 • physical barriers
• neutrophil
• T lymphocytes
• antibodies
• spleen
100 %
months
bacteria
Aspergillus
CMV
T lymphocytes
antibodies
spleen
Pneumococcus Haemophilus
VZV
antibodies
spleen
bacteria
Candida
HSV
barriers
neutrophil
T lymphocytes
antibodies
spleen
Protective mechanisms
aGvHD cGvHD
JM
![Page 3: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/3.jpg)
Tomblyn et al. BB&MT 2009
![Page 4: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/4.jpg)
Bacterial infections
Early after HSCT
(neutropenic phase)
![Page 5: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/5.jpg)
Febrile episodes in neutropenic patients – EORTC trials–
0
20
40
60
80
100
73-76 77-80 80-83 83-85 86-88 89-91 91-93 94-96
year of EORTC trial
Gram (-ve)
Gram (+ve)
year of EORTC study
with microbiological
diagnosis
33%
without microbiological
diagnosis
67%
![Page 6: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/6.jpg)
Febrile episodes (positive blood cultures) in neutropenic patients . Hospital Clínic 1991 - 2012
0
20
40
60
80
100
91-92 93-94 95-96 97-98 99-00 00-04 04-'08 08-´12
Gram (+)
Gram (-)
![Page 7: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/7.jpg)
2540 episodes of bacteriemia in neutropenic patients (<500/mL) *
* Hospital Clínic. Barcelona 1991-2009
Agent Isolates (%)
Staph. coagulase (-ve).
E. coli
P. aeruginosa
Streptococcus viridans
476
283
133
96
(32)
(19)
(9)
(6)
Mortality (%)
(5)
(19)
(21)
(9)
25
54
28
9
![Page 8: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/8.jpg)
gastro-
intestinal
tract
vascular access
Gram (-ve)
Gram (+ve)
Main sources of infection in neutropenic patients
![Page 9: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/9.jpg)
Clinical Infectious Diseases 2009: 49: 1 – 44.
![Page 10: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/10.jpg)
aerobic / anaerobic
1 / 100-1000
oxide-reduction gradient
translocation
- complement - antibodies
JM
![Page 11: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/11.jpg)
reduction of phagocytosis capacity - neutropenia
increased permeability of the mucosa - mucositis
increased density of aerobic bacteria - treat. antibiotics
primary
bacteraemia
JM
![Page 12: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/12.jpg)
Bacterial infections
Prophylaxis
Gastro-intestinal decontamination (GID) + low bacterial diets
![Page 13: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/13.jpg)
Cooked vs non cooked diets AML - induction therapy
Incidence of major infections
Gardner et al. JCO 2008; 26: 5684
RAW randomized
Higher incidence of Enterococcus
SRV=
RAW no randomized
COOKED randomized
![Page 14: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/14.jpg)
Profilaxis with non-absorbable antibiotics
(GVN) + isolation measures in 95
consecutive severe neutropenic patients
Isolation +
GVN
without
measures
Febrile episodes 40% 80%*
Clinically doc. Infect. 25% 55%*
Bacteriol. doc. Infect. 21% 53%*
Related deaths 8% 26%*
Ribas-Mundó et al. Cancer 1981
* p<0.01
Hospital Clínic Barcelona
Gentamicin
Vancomicin
Nistatin (Aerobic + anaerobic
flora)
HPA rooms
Sterile diets
![Page 15: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/15.jpg)
• van der Vaaij. Resistance to
colonization mechanisms. Infection 1983
Anaerobic flora
Selective
GID
Total
GID
Gram(-ve)
Quinolones era
![Page 16: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/16.jpg)
GID with fluoroquinolones
infections gram (-ve) microbiol. docum. infect. total infections days with fever
= gram (+ve) infections = fungal infections = clinically docum. infect. = infection-related deaths
Quinolone vs. Placebo or TMP-SMZ *
* Engels et al, JCO 1998 **Cruciani et al, JCO 2003
Emergence S. viridans & S. coagulase (-)
18 randomized studies / 1408 patients
Quinolone + gram (+ve) vs. Quinolone**
Same results adverse effects
9 randomized studies / 1202 patients
rifampicin, vancomycin, amoxicillin, roxithromycin, penicillin
![Page 17: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/17.jpg)
Bucaneve et al, NEJM 2005
Patients with acute Leukaemia
Probability of
survival
free
of fever (%) Levo
Placebo
p<0.01
GID with levofloxacin
![Page 18: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/18.jpg)
Imran et al. Eur J Clin Microbiol Infect Dis 2008
Meta-analysis randomized studies (2719 patients)
GID with quinolones
![Page 19: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/19.jpg)
1st European Conference on Infections in Leukemia (ECIL)
ECIL1 Guidelines. EJC supplement 2007: 5(2)
![Page 20: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/20.jpg)
1st European Conference on Infections in Leukemia (ECIL)
ECIL1 Guidelines. EJC supplement 2007: 5(2)
![Page 21: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/21.jpg)
Bacterial infections
Diagnosis
![Page 22: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/22.jpg)
To analyze epidemiologic exposures
1st
To analyze the predominant type of immuno- suppression
2nd
To evaluate preventive measures used
3rd
.
ciprofloxacin
cotrimoxazole
fluconazole
aciclovir
ganciclovir
. . .
isolation
measures . . .
vaccines
Exogenous infection (epidemic outbreaks, contact w child or other patients, isolation measures)
Mucosa flora status (previous Atb and infections)
Reactivation (travel, tuberculosis, serologies)
neutropenia
mucositis
T lymphocytes
antibodies
spleen
JM
![Page 23: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/23.jpg)
To analyze epidemiologic exposures
1st
To analyze the predominant type of immuno- suppression
2nd
To evaluate preventive measures used
3rd
.
ciprofloxacin
cotrimoxazole
fluconazole
aciclovir
ganciclovir
. . .
isolation
measures . . .
vaccines
Exogenous infection (epidemic outbreaks, contact w child or other patients, isolation measures)
Mucosa flora status (previous Atb and infections)
Reactivation (travel, tuberculosis, serologies)
neutropenia
mucositis
T lymphocytes
antibodies
spleen
Culture:
- Blood, urine & stools + any other focus
Imaging:
- Chest x-ray + CT/MRI/US (focus)
Biochemistry
- Basic + PCR + blood gasses
JM
![Page 24: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/24.jpg)
blood obtained through the catheter
> 100 UFC / mL
blood obtained from a peripheral vein
< 10 UFC / mL
difference between growing time > 2 h
catheter colonized or infected
JM
W/O microbiological
diagnosis 65-70%
60% of remaining
Gram (+ve)
![Page 25: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/25.jpg)
Bacterial infections
Treatment
![Page 26: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/26.jpg)
A, B, C of treatment of febrile neutropenia
It must be:
• Started immediately after onset of fever
• Based in an empirical approach
• Adapted to the flora usually observed in
each centre
• Adapted to the type of patient
• Adapted to the clinical situation
1
2
3
![Page 27: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/27.jpg)
1491 episodes of bacteraemia / fungemia
in neutropenic patients (< 500 / mL). 1991-2004*
Incidence and mortality by microorganisms
Microorganism (%)
• S. coag. neg. (32)
• E. coli (19)
• P. aeruginosa (9)
• Strept. Viridans (6)
• Enterococcus (6)
• S. aureus (5)
• Candida spp (4)
Death (%)
(5)
(19)
(21)
(9)
(18)
(21)
(40)
25 / 476
54 / 283
28 / 133
9 / 96
15 / 84
15 / 71
23 / 58
* Hospital Clínic. Barcelona JM
1 Adapted to centre
![Page 28: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/28.jpg)
Enterobact-BLEAs
non-ferm-GNB
S Aureus MR
Flora changes during severe disease evolution
Healthy
people
Severe
disease
Atb
>72 h
Long term
Atb - ICU
each
epithelium
its flora
flora
redistribution
flora
selection
multi-
resistant
flora
Haemophylus
S Aureus MS
Enterobacteria
Multi-R GNB
SPCN
Enterococcus
Candida
JM 2 Adapted to patient
![Page 29: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/29.jpg)
JM
Level of bacterial burden
pneumonia
meningitis
empiema
septic arthritis
endocarditis
osteomielitis
peritonitis, abscess
high > 107 UFC/mL low < 105 UFC/mL
(urinary infection)
primary bacteraemia
catheter infection
B-lactamic B-lactamic + aminoglucoside
3 Adapted to clinical situation
![Page 30: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/30.jpg)
• B-lactamic active against G(+ve) and G(-ve) including P. aeruginosa
- cefepime (8h), - piperacil.-tazobac., - imipenem o - meropenem - doripenem
JM
• aminoglucoside
- amikacin
+/-
![Page 31: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/31.jpg)
To add an aminoglucoside?
2 meta-analyses >4600 patients (Furno et al. Lancet Infect Dis 2002; Paul et al. Cochrane 2003)
+ 9 trials
Monotherapy = Betalactam + AG?
Betalactam + AG more toxic?
AG in initial regime (empirical or if G-ve documented)?
YES (AI)
YES (AI)
NO
(CIII)
ECIL conclusions 2007
ECIL1 Guidelines. EJC supplement 2007: 5(2)
![Page 32: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/32.jpg)
Eskape pathogens:
Enterococus faecium
Staphylococcus aureus
Klebsiella pneumoniae
Acinetobacter baumanii
Pseudomona aeruginosa
Enterobacter spp
![Page 33: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/33.jpg)
2011
Center with a high
incidence of
ESBL? (extended spectrum
beta-lactamases)
![Page 34: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/34.jpg)
![Page 35: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/35.jpg)
• B-lactamic active against G(+ve) and G(-ve) including P. aeruginosa
- cefepime (8h), - piperacil.-tazobac., - imipenem o - meropenem - doripenem
JM
• aminoglucoside
• anti-gram(+ve)
- amikacin
- glucop./daptom./linezo.
+/-
![Page 36: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/36.jpg)
Glycopeptides in neutropenic patients –main doubts -
1.- Upfront in the empirical therapy? Vardakas et al. Lancet Infect Dis 2005 (meta-analysis)
Paul et al. JAC 2005 (meta-analysis)
![Page 37: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/37.jpg)
Lancet Infect Dis 2005; 5: 431-439
odds ratios of treatment success without modification of the initial regimen
(1812 patients)
OR 1,63 95% CI 1,2-2,2
JM
odds ratios of mortality
(1073 patients)
OR 0,67 95% CI 0,4-1,05
![Page 38: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/38.jpg)
Lancet Infect Dis 2005; 5: 431-439
odds ratios of all adverse effects
(883 patients)
OR 4,98 95% CI 2,9-8,5
odds ratios of nephrotoxicity
(1508 patients)
OR 2,1 95% CI 1,1-3,9
JM
![Page 39: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/39.jpg)
Glycopeptides in neutropenic patients –main doubts -
1.- Upfront empirical therapy? Vardakas et al. Lancet Infect Dis 2005 (meta-analysis)
Paul et al. JAC 2005 (meta-analysis)
2.- In case of persistent fever after
initial broad spectrum empirical
antibiotic therapy? Cometta et al. CID 2003 (placebo controlled)
Erjavec et al. JAC 2000 (placebo-controlled)
![Page 40: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/40.jpg)
placebo
vanco
Glycopeptides if persistent fever after initial broad spectrum empirical Atb?
Cometta et al. CID 2003
![Page 41: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/41.jpg)
To add a glycopeptide?
At onset of fever
Persistent fever
MARSA colonization, hypotension or shock,
skin, soft tissue, catheter related
NO (DI)
NO (DI)
YES
(CIII)
ECIL conclusions 2007
ECIL1 Guidelines. EJC supplement 2007: 5(2)
Role of the less toxic and more
effective anti-gram (+ve) agents
- Linezolid
- Daptomycin ?
![Page 42: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/42.jpg)
• possible catheter infection
• severe mucositis
• colonization by MRSA
Summary: Initial empirical antibiotherapy in neutropenic patients with fever
antibiotic clinical situation
- meropenem (AI)
- imipenem (AII)
- pipera.-tazo (AII)
- cefepime (AII)
• fever without clinical focality
- glycopeptide or
- daptomycin
+ AII
BIII
AII
JM
![Page 43: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/43.jpg)
Initial empirical antibiotherapy in neutropenic patients with fever
antibiotic clinical situation
- meropenem (AI)
- imipenem (AII)
- pipera.-tazo (AII)
- cefepime (AII)
• fever without clinical focality
• focality (tiphlytis, pneumonia,..)
• previous Atb treatment (>5-7d)
• colonization with resistant G(-ve)
• high incidence of ESBL
AII
BIII
BIII
BIII
+ - aminoglucoside
JM
![Page 44: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/44.jpg)
Initial empirical antibiotherapy in neutropenic patients with fever
antibiotic clinical situation
- meropenem (AI)
- imipenem (AII)
- pipera.-tazo (AII)
- cefepime (AII)
• fever without clinical focality
• sepsis, shock, ARDS
• worsening after first days
of treatment
+ - aminoglucoside
- glycopeptide or
- daptomycin
+ AII
JM
![Page 45: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/45.jpg)
imip. 112
Elting L, et al Time to clinical response: An outcome of antibiotic therapy of febrile neutropenia with implications for quality and cost of care
J Clin Oncol 2000; 21: 3699-3706
cefta. 112
imip.+ vanco.
166
cefta.+ vanco.
98 P P
• time clinical resp.*
• response at 72 h
• days w Atb.
• days hospital.
5
33%
7
9
.003
.01
.04
.04
7
18%
9
12
5
29%
8
9
6
16%
9
13
.09
.03
.05
.02
* 24 h w/o fever and clinical improvement JM
![Page 46: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/46.jpg)
Bacterial infections
Late infections - capsulated bacteria -
![Page 47: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/47.jpg)
Capsulated bacteria (S. pneumoniae, H. influenzae, N meningitidis)
cGvHD
GvHD treat.
Functional
asplenia
Hypogammaglob
Absence of specific Ab
Infections
Bacterial infections late after HSCT
![Page 48: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/48.jpg)
Probability of pneumococcal sepsis
Capsulated bacteria (S. pneumoniae)
Kulkarni, et al. Blood 2000
Bacterial infections late after HSCT
Chronic GVHD
Allograft w/o chronic GVHD
Allo or TBI
non Allo non TBI
![Page 49: Bacterial infections in HSCT - European Society for Blood ... fileBacterial infections in HSCT Montserrat Rovira, Enric Carreras with the collaboration of Josep Mensa Hospital Clinic,](https://reader031.vdocuments.mx/reader031/viewer/2022022118/5cc520ec88c9936d678d1d6e/html5/thumbnails/49.jpg)
Bacterial infections Remember!
When evaluating a HSCT receptor with fever always think in other possible “rare” bacterial infections:
–Mycobacteria (de la Cámara et al, BMT 2000)
–Nocardia (Torres et al, Medicine (Balt.) 2002)
– Listeria (Rivero et al, Diagn Microbiol Infect Dis 2003)
–Legionella (Roig et al, Curr Opin Infect Dis 2003)
–Endemic diseases (travel, globalization!!)