Antimicrobial prophylaxis and the rate of blood stream infections and Clostridioides difficile in pediatric stem cell transplantation: A single‐center retrospective study

Abstract

Background:The use of prophylactic antibiotics in the pre-engraftment period to minimize the risk of bacteremia is debatable given concerns of Clostridioides difficile (C. diff), antibiotics resistance, and disruption of gut microbiota. Methods:We retrospectively reviewed the rate and characteristics of bacteremia and C. diff infections within the first 100 days post-HSCT in all pediatric patients who received routine antibacterial prophylaxis during HSCT from 2015 to 2018. C. diff infection was defined by the presence of three or more unformed stools in 24 h and positive stool test for C. diff or its toxins.Results: One hundred and thirty-five (100 allogeneic and 35 autologous) transplants in 123 patients were eligible for analysis. Median age at transplant was 7.1 (range 0.2-13.7), 67 (55%) were women, and diagnosis was malignant condition in 68 patients.Median time to neutrophil engraftment was 18 days (13-23). Cefepime or piperacillintazobactam prophylaxis was used in 105 (78%) and 28 (21%) of patients, respectively.Only five (3%) patients had bacteremia during the pre-engraftment period, and 13 (11%) patients developed bacteremia postengraftment. Septic shock was present in only one patient pre-engraftment and was due to gram-negative bacteria. All patients who developed bacteremia received MAC. Thirteen patients (10%) of patients fulfilled C. diff infection definition. There was no mortality related to bacterial infections among our patients. Conclusions:The use of antibiotic prophylaxis was associated with low rate of bacteremia in the pre-engraftment period and a 10% risk of C. diff infections. More studies are needed to better evaluate the efficacy of antibiotic prophylaxis in HSCT patients.

Clostridioides difficile infection in the allogeneic hematopoietic cell transplant recipient

“…11,[29][30][31][32] Children undergoing HCT are particularly vulnerable due to unique and non-modifiable risk factors, 33 but data on the incidence in this specific population are unfortunately quite scarce 34 and with some controversy. 12,33,[35][36][37][38] One study reported an 8% incidence, with higher rates in patients transplanted specifically for acute leukemia. 36 In another study, the incidence was 10% in the first 100 days post-HCT in pediatric patients receiving antibacterial prophylaxis, without significant correlation with primary disease, prior CDI or GvHD.…”

“…36 In another study, the incidence was 10% in the first 100 days post-HCT in pediatric patients receiving antibacterial prophylaxis, without significant correlation with primary disease, prior CDI or GvHD. 37 Recently, Ramanathan et al 38 performed a study on 826 patients with CDI after allogeneic-HCT between the start of conditioning and day 100 and a control group of 6723 patients without CDI. In this study, the incidence of CDI was higher in pediatric patients (2-18 years) at 18.7% than in adult patients at 10.2%.…”

“…Rates of CDI are increasing over time in children, 28 particularly in the immunocompromised host most often exposed to risk factors, including recent antibiotic use, chemotherapy, and prolonged hospitalization 11,29–32 . Children undergoing HCT are particularly vulnerable due to unique and non‐modifiable risk factors, 33 but data on the incidence in this specific population are unfortunately quite scarce 34 and with some controversy 12,33,35–38 . One study reported an 8% incidence, with higher rates in patients transplanted specifically for acute leukemia 36 .…”

“…One study reported an 8% incidence, with higher rates in patients transplanted specifically for acute leukemia 36 . In another study, the incidence was 10% in the first 100 days post‐HCT in pediatric patients receiving antibacterial prophylaxis, without significant correlation with primary disease, prior CDI or GvHD 37 …”