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1.
Levofloxacin prophylaxis and parenteral nutrition have a detrimental effect on intestinal microbial networks in pediatric patients undergoing HSCT
Fabbrini, M., D'Amico, F., Leardini, D., Muratore, E., Barone, M., Belotti, T., Forchielli, M. L., Zama, D., Pession, A., Prete, A., et al
Communications biology. 2023;6(1):36
Abstract
The gut microbiome (GM) has shown to influence hematopoietic stem cell transplantation (HSCT) outcome. Evidence on levofloxacin (LVX) prophylaxis usefulness before HSCT in pediatric patients is controversial and its impact on GM is poorly characterized. Post-HSCT parenteral nutrition (PN) is oftentimes the first-line nutritional support in the neutropenic phase, despite the emerging benefits of enteral nutrition (EN). In this exploratory work, we used a global-to-local networking approach to obtain a high-resolution longitudinal characterization of the GM in 30 pediatric HSCT patients receiving PN combined with LVX prophylaxis or PN alone or EN alone. By evaluating the network topology, we found that PN, especially preceded by LVX prophylaxis, resulted in a detrimental effect over the GM, with low modularity, poor cohesion, a shift in keystone species and the emergence of modules comprising several pathobionts, such as Klebsiella spp., [Ruminococcus] gnavus, Flavonifractor plautii and Enterococcus faecium. Our pilot findings on LVX prophylaxis and PN-related disruption of GM networks should be considered in patient management, to possibly facilitate prompt recovery/maintenance of a healthy and well-wired GM. However, the impact of LVX prophylaxis and nutritional support on short- to long-term post-HSCT clinical outcomes has yet to be elucidated.
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2.
Association of zinc deficiency with infectious complications in pediatric hematopoietic stem cell transplantation patients
Suwanphoerung, W., Klinmalai, C., Rattanasiri, S., Pakakasama, S., Anurathapan, U., Hongeng, S., Chongviriyaphan, N., Apiwattanakul, N.
PloS one. 2022;17(12):e0279439
Abstract
BACKGROUND Zinc plays essential roles in immune function and epithelial integrity. Patients undergoing hematopoietic stem cell transplantation (HSCT) often have low plasma zinc levels because of poor intake and diarrhea. We hypothesized that patients with zinc deficiency before HSCT had worse infectious complications after HSCT compared with patients with normal zinc levels. Citrulline, a marker of intestinal integrity, was also hypothesized to be lower in patients with zinc deficiency. PATIENTS AND METHODS Thirty patients undergoing HSCT at Ramathibodi Hospital during March 2020-September 2021 were enrolled. Blood samples for plasma zinc and citrulline were collected during the HSCT period. The 14- and 90-day outcomes after HSCT were prospectively recorded. RESULTS Twelve of 30 (40%) patients had zinc deficiency before HSCT. Zinc-deficient patients were younger (median (interquartile range): 6 (8.8) vs 13 (5.8) years old; p = 0.017). Zinc levels tended to increase after admission in both groups. Patients with zinc deficiency had lower citrulline levels than those with normal zinc levels. Citrulline levels decreased in both groups after stem cell infusion, and the level was not significantly different between the two groups. Zinc-deficient patients had a higher rate of bacterial infection within 90 days after HSCT than those with normal zinc levels (6 in 12 patients (50.0%) vs 1 in 18 patients (5.6%); odds ratio [OR]: 17.0; 95% confidence interval [CI]: 1.68-171.70; p = 0.016). This remained significant after adjustments for age (adjusted OR: 12.31; 95% CI: 1.084-139.92; p = 0.043). CONCLUSION The prevalence of zinc deficiency in pediatric patients undergoing HSCT was high. Zinc-deficient patients had lower citrulline levels and higher incidence of bacterial infection after HSCT. However, citrulline level was not different between patients with and without bacterial infections. It is worth to investigate whether zinc supplementation before HSCT can reduce bacterial infection after HSCT.
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3.
Intensive oral care can reduce bloodstream infection with coagulase-negative staphylococci after neutrophil engraftment in allogeneic hematopoietic stem-cell transplantation
Suwabe, T., Fuse, K., Katsura, K., Soga, M., Katagiri, T., Shibasaki, Y., Narita, M., Sone, H., Masuko, M.
Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2021
Abstract
PURPOSE Bloodstream infection (BSI) is a major complication of allogeneic hematopoietic stem-cell transplantation (allo-SCT). There are several causes of BSI; in particular, severe oral mucositis (OM) can induce BSI due to coagulase-negative staphylococci (CoNS). The OM severity may be reduced with intensive oral care. Thus, we evaluated whether the type of oral care affects the BSI incidence eventually. METHOD We performed retrospective analysis on 206 recipients who underwent allo-SCT from 2006 to 2017 at our institute. Intensive oral care by a dental specialist was performed for 111 recipients (intensive-care group) and self-oral care was performed by 95 recipients (self-care group). Incidence of BSI was assessed by type of the oral care, before neutrophil engraftment (pre-E-BSI) and after neutrophil engraftment (post-E-BSI) period until 180 days after allo-SCT. RESULT A total of 112 BSI occurred in 90 of the 206 recipients and 120 bacteria were identified, with CoNS being the most prevalent. There was no significant difference in the incidence of pre-E-BSI between the self-care and intensive-care groups (30.8% and 30.6%, respectively; P?=?0.508). Meanwhile, the incidence of post-E-BSI was significantly lower in the intensive-care group than in the self-care group (14.3% and 28.6%; P?=?0.008). In addition, the intensive-care group had significantly lower incidence of post-E-BSI with CoNS than the self-care group (8.5% and 21.5%, respectively; P?=?0.009). CONCLUSION Intensive oral care through the period of allo-HCT can significantly reduce the post-E-BSI occurrence, especially due to CoNS.
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4.
The nutrition risk index is associated with bacteraemia within 30 days after autologous stem cell transplantation in patients with multiple myeloma
Garzon Herazo, J. R., Mauricio Munoz Velandia, O., Solano, J. C., Molina Pimienta, L., Figueroa Lemus, W. J.
Transplant infectious disease : an official journal of the Transplantation Society. 2020;:e13302
Abstract
OBJECTIVES To assess whether the nutrition risk index (NRI) is associated with the risk of bacteraemia within the first days after autologous stem cell transplantation (ASCT) in patients with multiple myeloma (MM). MATERIALS AND METHODS Retrospective cohort study of adult patients with MM taken to ASCT at the Hospital Universitario San Ignacio (Bogota, Colombia) between 2005 and 2019. The outcome of interest was the incidence of bacteraemia at 30 days. Multivariate analysis was used to identify if the NRI was associated with bacteraemia, controlling by different confounding variables. RESULTS 124 patients with a median age of 58.5 years, (IQR 54 - 64) were included. 47.1% were in stage ISS III. 36.0% had moderate or severe malnourishment (NRI <97.5). 11.2% presented bacteraemia in the first 30 days after transplantation. In the univariate analysis, the NRI <97.5 was associated with bacteraemia (OR 1.88; 95% CI 1.30 - 2.72, p = 0.001), however this association was not significant in the multivariate analysis, unlike the presence mucositis (OR 11.59; 95% CI 1.9-68.3, <0.01), one or more previous lines of therapy (OR 12.0; 95% CI 2.1 - 67.4; p <0.01) and duration of aplasia (OR 1.70; 95% CI 1.2-2.4, p <0.01) CONCLUSIONS Patients with moderate or severe malnourishment have a higher incidence of bacteraemia in the 30 days post ASCT in patients with MM. Additional risk factors associated with bacteraemia include the presence of mucositis, one or more previous lines of therapy, and the duration of aplasia.
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nImproving Oral Health and Modulating the Oral Microbiome to Reduce Blood Stream Infections from Oral Organisms in Pediatric and Young Adult Hematopoietic Stem Cell Transplant Recipients: A Randomized Controlled Trial
Badia, P., Andersen, H., Haslam, D., S. Nelson A, Pate, A. R., Golkari, S., Teusink-Cross, A., Flesch, L., Bedel, A., Hickey, V., et al
Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation. 2020
Abstract
BACKGROUND Bloodstream infections (BSI) from oral organisms are a significant cause of morbidity and mortality in hematopoietic stem cell transplant (HSCT) recipients. There are no proven strategies to decrease BSI from oral organisms. The aim of this study was to evaluate the impact of daily xylitol wipes in improving oral health, decreasing BSI from oral organisms and modulating the oral microbiome in pediatric HSCT recipients. METHODS This was a single center 1:1 randomized controlled trial in pediatric HSCT recipients older than 2 years. Age matched healthy children were enrolled to compare the oral microbiome. The oral hygiene standard of care (SOC) group continued to receive the standard oral hygiene regimen. The xylitol group received daily oral xylitol wipes (with 0.7gm xylitol) in addition to the SOC. The intervention started from the beginning of the transplant chemotherapy regimen to 28 days following transplantation. The primary outcome was oral health at interval time points, and secondary outcomes included blood stream infections from oral organisms in the first 30 days following transplantation, oral microbiome abundance, and diversity and oral pathogenic organism abundance. RESULTS The study was closed early due to efficacy after an interim analysis of the first 30 HSCT recipients was performed (SOC group (n=16) and xylitol group (n=14)). The xylitol group had a significantly lower rate of gingivitis at days 7, 14, and 28 following transplantation (p=0.031, p=0.0039, p=0.0005); oral plaque at days 7 and 14 following transplantation (p=0.045, p=0.0023); and oral ulcers greater than 10 mm at day 14 (p=0.049) compared to the SOC group. The xylitol group had no BSI from oral organisms compared to SOC group which had four (p=0.04). The xylitol group had significantly lower abundance of potential BSI pathogens such as Staphylococcus aureus (p=0.036), Klebsiella pneumoniae (p=0.033), and Streptococcus species (p=0.011) at day following transplantation compared to the SOC group. Healthy children and young adults had significantly increased oral microbiome diversity compared to all HSCT recipients (<0.001). CONCLUSIONS AND RELEVANCE The addition of xylitol to standard oral care significantly improves oral health, decreases BSI from oral organisms and decreases pathogenic oral organism abundance in pediatric and young adult HSCT recipients.
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Revisiting Infectious Complications Following Total Parenteral Nutrition Use During Hematopoietic Stem Cell Transplantation
Rubin, H., Mehta, J., Fong, J. L., Greenberg, D., GrusChak, S., Trifilio, S.
Journal of the advanced practitioner in oncology. 2020;11(7):675-682
Abstract
BACKGROUND Total parenteral nutrition (TPN) is frequently used to manage caloric needs during hematopoietic stem cell transplantation (HSCT). Previous studies in transplant patients who received TPN have reported widely discordant results with regard to infection and mortality, and risk factors for TPN-related infection remain unclear. METHOD We conducted a retrospective study of all HSCT recipients treated with TPN between 2005 to 2014 at Northwestern Memorial Hospital to determine the incidence and epidemiology of infections. Electronic records were used to identify patients treated with TPN for at least 2 days who developed infection. RESULTS Among 198 patients treated with TPN, 30% developed documented infection. Total parenteral nutrition treatment duration (13 vs. 7 days; p < .0001) and the timing of TPN initiation (> day 9 post HSCT; p < .0001) were significantly higher in patients who received TPN and developed infection. Receipt of an allogeneic transplant was associated with increased risk for infection (p < .0138), and day 60 mortality was significantly higher in TPN-treated patients with infection (p < .0001). CONCLUSION Stem cell recipients who receive TPN, especially from an allogeneic donor, have high rates of infection and mortality. Minimizing TPN exposure may reduce the chance for infection.
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7.
Enteral nutrition protects children undergoing allogeneic hematopoietic stem cell transplantation from blood stream infections
Zama, D., Muratore, E., Biagi, E., Forchielli, M. L., Rondelli, R., Candela, M., Prete, A., Pession, A., Masetti, R.
Nutrition journal. 2020;19(1):29
Abstract
Enteral Nutrition (EN) is recommended as first line nutritional support for patients undergoing Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT), but only few studies exist in the literature which compare EN to Parenteral Nutrition (PN) in the paediatric population.Forty-two consecutive paediatric patients undergoing allo-HSCT at our referral centre between January 2016 and July 2019 were evaluated. Post-transplant and nutritional outcomes of patients receiving EN for more than 7 days (EN group, n = 14) were compared with those of patients receiving EN for fewer than 7 days or receiving only PN (PN group, n = 28). In the EN group, a reduced incidence of Blood Stream Infections (BSI) was observed (p = 0.02) (n = 2 vs. n = 15; 14.3% vs. 53.6%). The type of nutritional support was also the only variable independently associated with BSI in the multivariate analysis (p = 0.03). Platelet engraftment was shorter in the PN group than in the EN group for a threshold of > 20*10(9)/L (p = 0.04) (23.1 vs 35.7 days), but this correlation was not confirmed with a threshold of > 50*10(9)/L. The Body Mass Index (BMI) and the BMI Z-score were no different in the two groups from admission to discharge.Our results highlight that EN is a feasible and nutritionally adequate method of nutritional support for children undergoing allo-HSCT in line with the present literature. Future functional studies are needed to better address the hypothesis that greater intestinal eubyosis maintained with EN may explain the observed reduction in BSI.
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8.
Supportive care during pediatric hematopoietic stem cell transplantation: beyond infectious diseases. A report from workshops on supportive care of the Pediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT)
Nava, T., Ansari, M., Dalle, J. H., de Heredia, C. D., Gungor, T., Trigoso, E., Falkenberg, U., Bertaina, A., Gibson, B., Jarisch, A., et al
Bone marrow transplantation. 2020
Abstract
Hematopoietic stem cell transplantation (HSCT) is currently the standard of care for many malignant and nonmalignant blood diseases. As several treatment-emerging acute toxicities are expected, optimal supportive measurements critically affect HSCT outcomes. The paucity of good clinical studies in supportive practices gives rise to the establishment of heterogeneous guidelines across the different centers, which hampers direct clinical comparison in multicentric studies. Aiming to harmonize the supportive care provided during the pediatric HSCT in Europe, the Pediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT) promoted dedicated workshops during the years 2017 and 2018. The present paper describes the resulting consensus on the management of sinusoidal obstructive syndrome, mucositis, enteral and parenteral nutrition, iron overload, and emesis during HSCT.
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9.
Effectiveness of Bath Wipes After Hematopoietic Cell Transplantation: A Randomized Trial
Kjellin, M., Qudeimat, A., Browne, E., Keerthi, D., Sunkara, A., Kang, G., Winfield, A., Giannini, M. A., Maron, G., Hayden, R., et al
Journal of Pediatric Oncology Nursing : Official Journal of the Association of Pediatric Oncology Nurses. 2020;37(6):390-397
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Abstract
Objective: Bacteremia is a leading cause of morbidity and mortality in children undergoing hematopoietic cell transplantation (HCT). Infections of vancomycin-resistant enterococci (VRE) and multidrug resistant (MDR) gram-negative rods (GNRs) are common in this population. Our objective was to assess whether experimental bath wipes containing silver were more effective than standard bath wipes containing soap at reducing skin colonization by VRE and MDR GNRs, and nonmucosal barrier injury bacteremia. Study Design: Patients undergoing autologous or allogeneic HCT in a tertiary referral center were randomized to receive experimental or standard bath wipes for 60 days post-HCT. Skin swabs were collected at baseline, discharge, and day +60 post-HCT. The rate of VRE colonization was chosen as the marker for efficacy. Results: Experimental bath wipes were well tolerated. Before the study, the rate of colonization with VRE in HCT recipients was 25%. In an interim analysis of 127 children, one (2%) patient in the experimental arm and two (3%) in the standard arm were colonized with VRE. Two (3%) patients had nonmucosal barrier injury bacteremia in the standard arm, with none in the experimental arm. MDR GNRs were not isolated. The trial was halted because the interim analyses indicated equivalent efficacy of the two methods. Conclusions: Skin cleansing with silver-containing or standard bath wipes resulted in very low and equivalent rates of bacteremia and colonization with VRE and MDR GNRs in children post-HCT. Future studies in other high-risk populations are needed to confirm these results.
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Nutritional risk index as a risk factor for breakthrough candidemia in allogeneic hematopoietic stem cell transplantation
Kaito, S., Sekiya, N., Najima, Y., Suzuki, T., Wada, A., Adachi, H., Konuma, R., Kishida, Y., Nagata, A., Konishi, T., et al
Bone marrow transplantation. 2019