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Results of an International Collaboration: Implementing Antibacterial Prophylaxis in a Pediatric Hematopoietic Stem Cell Transplant Program
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Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
assay, the median peak of stool volume was higher in this group. Conclusions: Detection of positive stool C. difficile Toxin B is common after MA and RI conditioning allogeneic HSCT and when detected, it occurred at the first stool test in the majority of the patients. Our findings suggest that in the immediate peri-transplant period, the likelihood of detecting a positive stool PCR assay for C difficile Toxin B following a previous negative stool assay is low. Whether positive stool C. difficile Toxin B assay represents commensal colonization vs. infection is yet to be determined and requires further investigation.
648 Results of an International Collaboration: Implementing Antibacterial Prophylaxis in a Pediatric Hematopoietic Stem Cell Transplant Program Misty Evans 1, Abdulhadi I. Al-Zaben 2, Sheree Allen 3, Anas Haroun 4, Eman Khattab 5, Haydar A. Frangoul 6, Ayad Ahmed Hussein 4, Leena Choi 7. 1 Pediatric Blood and Marrow Transplant, The Children’s Hospital at TriStar Centennial and Sarah Cannon Research Institute, Nashville, TN; 2 Bone Marrow and Stem Cell Transplantation Program, King Hussein Cancer Center, amman, Jordan; 3 School of Nursing, Vanderbilt University, Nashville, TN; 4 Bone Marrow and Stem Cell Transplantation Program, King Hussein Cancer Center, Amman, Jordan; 5 King Hussein Cancer Center, Amman, Jordan; 6 The Children’s Hospital at TriStar Centennial and Sarah Cannon Reseach Institute, Nashville, TN; 7 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN Background: Hematopoietic stem cell transplant (HSCT) recipients are at significant risk for developing serious infectious complications. Bacterial infections are the leading cause of morbidity and treatment-related mortality during transplantation. Methods: A long standing quality improvement collaboration exists between pediatric HSCT providers at Vanderbilt Children’s Hospital (VCH) and the pediatric HSCT program at King Hussein Cancer Center (KHCC) in Jordan. Prior review of infectious complications at KHCC revealed a bacterial infection rate of 39% during the neutropenic phase of HSCT. In an effort to decrease bacterial infections at KHCC, the HSCT team implemented VCH clinical practice guideline of administering antibacterial prophylaxis prior to neutrophil engraftment. Retrospective review evaluated the effect of antibacterial prophylaxis on the incidence of bacterial infections 2 years prior and 1 year following implementation. Results: A total of 174 patients were included in the study, 108 in the pre-intervention group and 66 who received prophylaxis with cefepime. The groups were comparable for age, gender, transplant type, primary disease, and conditioning regimen. Patients in both the pre and post-intervention groups experienced similar median days of neutropenia, 14.8 and 13.4 days respectively (p¼0.108). A total of 19 (17.6%) patients in the pre-intervention group experienced at least one bacterial infection during transplant; while a total of 3 (4.5%) experienced 3 infections in the prophylaxis group. The odds of developing bacterial infection during pre-engraftment was significantly lower in
patients who were treated with antibacterial prophylaxis compared to those who were not treated with prophylaxis (OR¼ 0.25; 95% CI: 0.07 to 0.92; p ¼ 0.037). In multivariate analysis neither malignant disease (HR¼0.48; 95% C: 0.12 to 1.87; p¼0.290), allogeneic transplant (HR¼1.43; 95% CI: 0.50 to 4.11; p¼0.510), myeloablative conditioning regimen (HR¼0.34; 95% CI: 0.04 to 2.75; p¼0.311), nor age (HR¼1.01; 95% CI: 0.95 to 1.08; p¼0.707) was significantly associated with the risk of bacterial infection. The only variable associated with significant decrease in bacterial infections was the use of antibacterial prophylaxis (HR¼0.28; 95% CI: 0.08 to 0.99; p¼0.048). At day 40 post-transplant the probability of bacterial infection free survival was 95.1% (95% CI: 89.9 to 100) for those who received prophylaxis compared to 81.5 % (95% CI: 74.1 to 89.6) for those who did not receive prophylaxis. The length of stay was significantly shorter in patients who were treated with antibacterial prophylaxis 30.3 days versus 37.7 days (HR 0.16; 95% CI: 0.06 to 0.25; p¼0.002). Conclusion: Antibacterial prophylaxis can significantly decrease the incidence of bacterial infections and significantly reduce the length of stay following hematopoietic stem cell transplant in children.
649 Purtscher-like Retinopathy: A Rare Complication of HSCT-Associated Thrombotic Microangiopathy Katherine Lynn Voigt 1, Paul Castillo 2, Charlene Crockett 3, Caridad Martinez 2, Kathryn Leung 2, Ghadir Sasa 2, Robert Garoon 3, Robert A. Krance 2, Swati Naik 2. 1 Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX; 2 Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children’s Hospital Cancer Center, Methodist Hospital Houston, Houston, TX; 3 Department of Ophthalmology, Baylor College of Medicine, Cullen Eye Institute, Houston, TX Introduction: We describe here a case of Purtscher-like retinopathy (PLR) linked with Hematopoietic Stem Cell Transplant (HSCT) associated thrombotic microangiopathy (TA-TMA). TA-TMA causes endothelial damage and results in micro-thrombi in capillaries and arterioles. PLR is associated with micro-thrombi that occlude the retinal arteries and cause retinal injury. This report describes the clinical course for PLR which has similar features to and can mimic hypertensive retinopathy. Case study: The patient is an 18 year old male who underwent a mismatched unrelated donor HSCT for relapsed ALL. On day+167, the patient was diagnosed with TA-TMA based on standard defined criteria. On day+185, he presented with acute onset of blurred vision with findings of multiple white retinal patches, retinal hemorrhages, and macular edema, thought initially to be hypertensive retinopathy then on further evaluation was determined to be PLR. Fluorescein angiography and optical coherence tomography confirmed vascular leakage and microangiopathic macular edema (Fig 1a). The patient was treated with intravitreal steroid injections (triamcinolone acetonide injectable suspension) with dramatic improvement of vision from decreased macular edema by day 6 (Fig 1b) and complete resolution of macular edema by week 6 post-intravitreal injection (Fig 1c).
Abstracts / Biol Blood Marrow Transplant 22 (2016) S19eS481
assay, the median peak of stool volume was higher in this group. Conclusions: Detection of positive stool C. difficile Toxin B is common after MA and RI conditioning allogeneic HSCT and when detected, it occurred at the first stool test in the majority of the patients. Our findings suggest that in the immediate peri-transplant period, the likelihood of detecting a positive stool PCR assay for C difficile Toxin B following a previous negative stool assay is low. Whether positive stool C. difficile Toxin B assay represents commensal colonization vs. infection is yet to be determined and requires further investigation.
648 Results of an International Collaboration: Implementing Antibacterial Prophylaxis in a Pediatric Hematopoietic Stem Cell Transplant Program Misty Evans 1, Abdulhadi I. Al-Zaben 2, Sheree Allen 3, Anas Haroun 4, Eman Khattab 5, Haydar A. Frangoul 6, Ayad Ahmed Hussein 4, Leena Choi 7. 1 Pediatric Blood and Marrow Transplant, The Children’s Hospital at TriStar Centennial and Sarah Cannon Research Institute, Nashville, TN; 2 Bone Marrow and Stem Cell Transplantation Program, King Hussein Cancer Center, amman, Jordan; 3 School of Nursing, Vanderbilt University, Nashville, TN; 4 Bone Marrow and Stem Cell Transplantation Program, King Hussein Cancer Center, Amman, Jordan; 5 King Hussein Cancer Center, Amman, Jordan; 6 The Children’s Hospital at TriStar Centennial and Sarah Cannon Reseach Institute, Nashville, TN; 7 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN Background: Hematopoietic stem cell transplant (HSCT) recipients are at significant risk for developing serious infectious complications. Bacterial infections are the leading cause of morbidity and treatment-related mortality during transplantation. Methods: A long standing quality improvement collaboration exists between pediatric HSCT providers at Vanderbilt Children’s Hospital (VCH) and the pediatric HSCT program at King Hussein Cancer Center (KHCC) in Jordan. Prior review of infectious complications at KHCC revealed a bacterial infection rate of 39% during the neutropenic phase of HSCT. In an effort to decrease bacterial infections at KHCC, the HSCT team implemented VCH clinical practice guideline of administering antibacterial prophylaxis prior to neutrophil engraftment. Retrospective review evaluated the effect of antibacterial prophylaxis on the incidence of bacterial infections 2 years prior and 1 year following implementation. Results: A total of 174 patients were included in the study, 108 in the pre-intervention group and 66 who received prophylaxis with cefepime. The groups were comparable for age, gender, transplant type, primary disease, and conditioning regimen. Patients in both the pre and post-intervention groups experienced similar median days of neutropenia, 14.8 and 13.4 days respectively (p¼0.108). A total of 19 (17.6%) patients in the pre-intervention group experienced at least one bacterial infection during transplant; while a total of 3 (4.5%) experienced 3 infections in the prophylaxis group. The odds of developing bacterial infection during pre-engraftment was significantly lower in
patients who were treated with antibacterial prophylaxis compared to those who were not treated with prophylaxis (OR¼ 0.25; 95% CI: 0.07 to 0.92; p ¼ 0.037). In multivariate analysis neither malignant disease (HR¼0.48; 95% C: 0.12 to 1.87; p¼0.290), allogeneic transplant (HR¼1.43; 95% CI: 0.50 to 4.11; p¼0.510), myeloablative conditioning regimen (HR¼0.34; 95% CI: 0.04 to 2.75; p¼0.311), nor age (HR¼1.01; 95% CI: 0.95 to 1.08; p¼0.707) was significantly associated with the risk of bacterial infection. The only variable associated with significant decrease in bacterial infections was the use of antibacterial prophylaxis (HR¼0.28; 95% CI: 0.08 to 0.99; p¼0.048). At day 40 post-transplant the probability of bacterial infection free survival was 95.1% (95% CI: 89.9 to 100) for those who received prophylaxis compared to 81.5 % (95% CI: 74.1 to 89.6) for those who did not receive prophylaxis. The length of stay was significantly shorter in patients who were treated with antibacterial prophylaxis 30.3 days versus 37.7 days (HR 0.16; 95% CI: 0.06 to 0.25; p¼0.002). Conclusion: Antibacterial prophylaxis can significantly decrease the incidence of bacterial infections and significantly reduce the length of stay following hematopoietic stem cell transplant in children.
649 Purtscher-like Retinopathy: A Rare Complication of HSCT-Associated Thrombotic Microangiopathy Katherine Lynn Voigt 1, Paul Castillo 2, Charlene Crockett 3, Caridad Martinez 2, Kathryn Leung 2, Ghadir Sasa 2, Robert Garoon 3, Robert A. Krance 2, Swati Naik 2. 1 Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX; 2 Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children’s Hospital Cancer Center, Methodist Hospital Houston, Houston, TX; 3 Department of Ophthalmology, Baylor College of Medicine, Cullen Eye Institute, Houston, TX Introduction: We describe here a case of Purtscher-like retinopathy (PLR) linked with Hematopoietic Stem Cell Transplant (HSCT) associated thrombotic microangiopathy (TA-TMA). TA-TMA causes endothelial damage and results in micro-thrombi in capillaries and arterioles. PLR is associated with micro-thrombi that occlude the retinal arteries and cause retinal injury. This report describes the clinical course for PLR which has similar features to and can mimic hypertensive retinopathy. Case study: The patient is an 18 year old male who underwent a mismatched unrelated donor HSCT for relapsed ALL. On day+167, the patient was diagnosed with TA-TMA based on standard defined criteria. On day+185, he presented with acute onset of blurred vision with findings of multiple white retinal patches, retinal hemorrhages, and macular edema, thought initially to be hypertensive retinopathy then on further evaluation was determined to be PLR. Fluorescein angiography and optical coherence tomography confirmed vascular leakage and microangiopathic macular edema (Fig 1a). The patient was treated with intravitreal steroid injections (triamcinolone acetonide injectable suspension) with dramatic improvement of vision from decreased macular edema by day 6 (Fig 1b) and complete resolution of macular edema by week 6 post-intravitreal injection (Fig 1c).