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We developed an immunodeficiency scoring index for respiratory syncytial virus (ISI-RSV) infection, based on a cohort of 237 allogeneic hematopoietic cell transplant (allo-HCT) recipients, that can predict the risk of progression to lower respiratory tract infection (LRTI) and RSV-associated mortality. A weighted index was calculated using adjusted hazard ratios for immunodeficiency markers. Based on the ISI-RSV (range, 0-12), patients were stratified into low (0-2), moderate (3-6), and high (7-12) risk groups. A significant trend of increasing incidence of LRTI and RSV-associated mortality was observed as the risk increased from low to moderate to high (P < .001). Patients in the high-risk group had the greatest benefit of ribavirin-based therapy at the upper respiratory tract infection stage and the highest risk for progression to LRTI and death when antiviral therapy was not given (6.5 [95% confidence interval (CI), 1.8-23.6] and 8.1 [95% CI, 1.1-57.6], respectively). The ISI-RSV is designed to stratify allo-HCT recipients with RSV infection into groups according to their risk for progression to LRTI and RSVassociated mortality. Identification of high-risk groups using this index would distinguish patients who would benefit the most from antiviral therapy, mainly with aerosolized ribavirin. The ISI-RSV should be validated in a multiinstitutional study. (Blood. 2014;123(21):3263-3268)

Our results demonstrate that RSV infections are a significant cause of morbidity and mortality in high-risk allo-HSCT recipients and ribavirin-based antiviral therapy at the URTI stage had a positive impact on both outcomes in this vulnerable population with multiple risk factors.

Background Despite increasing data on the impact of the microbiome on cancer, the dynamics and role of the microbiome in infection during acute myelogenous leukemia (AML) therapy are unknown. Thus, we sought to determine relationships between microbiome composition and infectious outcomes in AML patients receiving induction chemotherapy (IC). Methods Buccal and fecal specimens (478 samples) were collected twice weekly from 34 AML patients undergoing IC. Oral and stool microbiomes were characterized by 16S rRNA V4 sequencing using Illumina MiSeq. Microbial diversity and genera composition were associated with clinical outcomes. Results Baseline stool α-diversity was significantly lower in patients that developed infections during IC compared to those that did not (P = 0.047). Significant decreases in both oral and stool microbial α-diversity were observed over the course of IC, with a linear correlation between α-diversity change at the two sites (P = 0.02). Loss of both oral and stool α-diversity was significantly associated with carbapenem receipt (P < 0.01). Domination events by the majority of genera were transient (median duration = 1 sample), while the number of domination events by pathogenic genera significantly increased over the course of IC (P=0.002). Moreover, patients who lost microbial diversity over the course of induction chemotherapy were significantly more likely to contract a microbiologically documented infection within the 90 days post-IC neutrophil recovery (P=0.04). Conclusion These data present the largest longitudinal analyses of oral and stool microbiomes in AML patients and suggest that microbiome measurements could assist with mitigation of infectious complications of AML therapy.

Continuing Medical Education onlineThis activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and the American Society of Hematology. Medscape, LLC is accredited by the ACCME to provide continuing medical education for physicians. Medscape, LLC designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity. All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 70% minimum passing score and complete the evaluation at http://www.medscape.org/journal/blood; and (4) view/print certificate. For CME questions, see page 2969. Disclosures The authors, the Associate Editor Martin S. Tallman, and CME questions author Laurie Barclay, freelance writer and reviewer, Medscape, LLC, declare no competing financial interests. Learning objectives Upon completion of this activity, participants will be able to:1. Describe the prevalence and clinical characteristics of parainfluenza virus (PIV) infections in patients with leukemia or HSCT, based on a medical record review.2. Describe outcomes of PIV infections in patients with leukemia or HSCT and the factors predicting progression to pneumonia, based on a medical record review.3. Describe risk factors for mortality from PIV infections in patients with leukemia or HSCT, based on a medical record review.

The role of the environment in harboring and transmitting multidrug-resistant organisms has become clearer due to a series of publications linking environmental contamination with increased risk of hospital-associated infections. The incidence of antimicrobial resistance is also increasing, leading to higher morbidity and mortality associated with hospital-associated infections. The purpose of this review is to evaluate the evidence supporting the existing methods of environmental control of organisms: environmental disinfection, contact precautions, and hand hygiene. These methods have been routinely employed, but transmission of multidrug-resistant organisms continues to occur in healthcare facilities throughout the country and worldwide. Several new technologies have entered the healthcare market that have the potential to close this gap and enhance the containment of multidrugresistant organisms: improved chemical disinfection, environmental monitoring, molecular epidemiology, self-cleaning surfaces, and automated disinfection systems. A review of the existing literature regarding these interventions is provided. Overall, the role of the environment is still underestimated and new techniques may be required to mitigate the role that environmental transmission plays in acquisition of multidrug-resistant organisms.

Patients with CDI given a rifaximin chaser regimen experienced a decreased incidence of recurrent diarrhoea compared with placebo.

HCT recipients with RSV infections had similar outcomes when treated with ARBV or ORBV. Oral ribavirin may be an effective alternative to aerosolized ribavirin for treatment of RSV in HCT recipients, with potential significant cost savings.