ABSTRACT
Carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) infections are an emerging cause of death after hematopoietic stem cell transplantation (HSCT). In allogeneic transplants, mortality rate may rise up to 60%. We retrospectively evaluated 540 patients receiving a transplant from an auto- or an allogeneic source between January 2011 and October 2015. After an Institutional increase in the prevalence of KPC-Kp bloodstream infections (BSI) in June 2012, from July 2012, 366 consecutive patients received the following preventive measures: (i) weekly rectal swabs for surveillance; (ii) contact precautions in carriers (iii) early-targeted therapy in neutropenic febrile carriers. Molecular typing identified KPC-Kp clone ST512 as the main clone responsible for colonization, BSI and outbreaks. After the introduction of these preventive measures, the cumulative incidence of KPC-Kp BSI (P=0.01) and septic shocks (P=0.01) at 1 year after HSCT was significantly reduced. KPC-Kp infection-mortality dropped from 62.5% (pre-intervention) to 16.6% (post-intervention). Day 100 transplant-related mortality and KPC-Kp infection-related mortality after allogeneic HSCT were reduced from 22% to 10% (P=0.001) and from 4% to 1% (P=0.04), respectively. None of the pre-HSCT carriers was excluded from transplant. These results suggest that active surveillance, contact precautions and early-targeted therapies, may efficiently control KPC-Kp spread and related mortality even after allogeneic HSCT.
Subject(s)
Bacterial Proteins/biosynthesis , Hematologic Neoplasms , Hematopoietic Stem Cell Transplantation , Klebsiella Infections , Klebsiella pneumoniae , Shock, Septic , beta-Lactamases/biosynthesis , Adolescent , Adult , Aged , Allografts , Autografts , Female , Follow-Up Studies , Hematologic Neoplasms/mortality , Hematologic Neoplasms/therapy , Humans , Klebsiella Infections/genetics , Klebsiella Infections/mortality , Klebsiella Infections/therapy , Klebsiella pneumoniae/genetics , Klebsiella pneumoniae/metabolism , Klebsiella pneumoniae/pathogenicity , Male , Middle Aged , Shock, Septic/genetics , Shock, Septic/mortality , Shock, Septic/therapySubject(s)
Hematopoietic Stem Cell Transplantation , Sirolimus/administration & dosage , Transplantation Conditioning , Triazoles/administration & dosage , Adolescent , Adult , Aged , Female , Follow-Up Studies , Hodgkin Disease/therapy , Humans , Leukemia, Myeloid, Acute/therapy , Lymphoma, Non-Hodgkin/therapy , Male , Middle Aged , Multiple Myeloma/therapy , Remission Induction , Risk , Transplantation, Homologous , Treatment Outcome , Young AdultABSTRACT
Outcomes after unmanipulated haploidentical stem cell transplantation (Haplo) and after unrelated cord blood transplantation (UCBT) are encouraging and have become alternative options to treat patients with high-risk acute leukemia without human leukocyte antigen (HLA) matched donor. We compared outcomes after UCBT and Haplo in adults with de novo acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). Median follow-up was 24 months. Analysis was performed separately for patients with AML, n=918 (Haplo=360, UCBT=558) and ALL, n=528 (Haplo=158 and UCBT=370). UCBT was associated with delayed engraftment and higher graft failure in both AML and ALL recipients. In multivariate analysis, UCBT was associated with lower incidence of chronic graft-vs-host disease both in the AML group (hazard ratio (HR)=0.63, P=0.008) and in the ALL group (HR=0.58, P=0.01). Not statistically significant differences were observed between Haplo and UCBT for relapse incidence (HR=0.95, P=0.76 for AML and HR=0.82, P=0.31 for ALL), non-relapse mortality (HR=1.16, P=0.47 for AML and HR=1.23, P=0.23 for ALL) and leukemia-free survival (HR 0.78, P=0.78 for AML and HR=1.00, P=0.84 for ALL). There were no statistically differences on main outcomes after unmanipulated Haplo and UCBT, and both approaches are valid for acute leukemia patients lacking a HLA matched donor. Both strategies expand the donor pool for patients in need.
Subject(s)
Cord Blood Stem Cell Transplantation , HLA Antigens/immunology , Hematopoietic Stem Cell Transplantation , Leukemia, Myeloid, Acute/immunology , Leukemia, Myeloid, Acute/therapy , Precursor Cell Lymphoblastic Leukemia-Lymphoma/immunology , Precursor Cell Lymphoblastic Leukemia-Lymphoma/therapy , Adolescent , Adult , Aged , Female , Follow-Up Studies , Graft Survival , Graft vs Host Disease/etiology , Graft vs Host Disease/prevention & control , Histocompatibility Testing , Humans , Leukemia, Myeloid, Acute/mortality , Male , Middle Aged , Precursor Cell Lymphoblastic Leukemia-Lymphoma/mortality , Recurrence , Risk Factors , Transplantation Conditioning , Transplantation, Homologous , Treatment Outcome , Young AdultABSTRACT
The use of unmanipulated graft is increasingly adopted in the setting of allogeneic hematopoietic stem cell transplantation from haploidentical family donors (haplo-SCT) in acute leukemia (AL). We analyzed the outcome of 229 adult patients with de novo AL, who received an unmanipulated haploidentical transplant as their first allo-SCT between 2007 and 2011. Median follow-up was 30 months. Disease status at transplant was: first complete remission (CR1) for 77, second CR (CR2) for 56, and advanced for 96 patients. One hundred and seventy-one patients received in vivo T-cell depletion by monoclonal antibodies (75%). The 60-day cumulative incidence (CI) of engraftment was 93±2%. The 100-day CI of acute graft-versus-host disease (GvHD) was 32±3% for grade II-IV, 12±3% for grade III-IV. The 3-year CI of chronic GvHD was 34±3%. The 3-year CI of non-relapse mortality was 31±4% with in vivo T-cell depletion and 17±5% without. At 3 years, for patients transplanted in CR1, CR2 or advanced disease leukemia-free survival was 44±6, 42±7 and 12±3%, overall survival was 55±6, 51±7 and 14±4% and CI of relapse was 32±6, 24±6 and 61±5%, respectively. These data suggest that unmanipulated haplo-SCT is a valid treatment option for adult AL patients in complete remission lacking a matched donor.
Subject(s)
Graft vs Host Disease/immunology , Hematopoietic Stem Cell Transplantation/methods , Leukemia, Myeloid, Acute/therapy , Precursor Cell Lymphoblastic Leukemia-Lymphoma/therapy , Adolescent , Adult , Aged , Alleles , Antibodies, Monoclonal/immunology , Disease-Free Survival , Female , Histocompatibility Testing , Humans , Leukemia, Myeloid, Acute/metabolism , Lymphocyte Depletion , Male , Middle Aged , Precursor Cell Lymphoblastic Leukemia-Lymphoma/metabolism , Recurrence , Remission Induction , Stem Cell Transplantation , Time Factors , Transplantation Conditioning/methods , Transplantation, Homologous , Treatment Outcome , Young AdultABSTRACT
Neisseria cinerea is an organism that has only recently been implicated as a human pathogen. In this case, N. cinerea was identified as the cause of ophthalmia neonatorum (conjunctivitis) in a 2-day-old girl.
