Healthcare Burden, Risk Factors, and Outcomes of Mucosal Barrier Injury Laboratory-Confirmed Bloodstream Infections after Stem Cell Transplantation

Abstract

Mucosal barrier injury laboratory-confirmed bloodstream infections (MBI-LCBIs) lead to significant morbidity, mortality, and healthcare resource utilization in hematopoietic stem cell transplant (HSCT) patients. Determination of the healthcare burden of MBI-LCBIs and identification of patients at risk of MBI-LCBIs will allow researchers to identify strategies to reduce MBI-LCBI rates. The objective of our study was to describe the incidence, risk factors, timing, and outcomes of MBI-LCBIs in hematopoietic stem cell transplant patients. We performed a retrospective analysis of 374 patients who underwent HSCT at a large free-standing academic children’s hospital to determine the incidence, risk factors, and outcomes of patients that developed a bloodstream infection (BSI) including MBI-LCBI, central line–associated BSI (CLABSI), or secondary BSI in the first year after HSCT. Outcome measures included nonrelapse mortality (NRM), central venous catheter removal within 7 days of positive culture, shock, admission to the pediatric intensive care unit (PICU) within 48 hours of positive culture, and death within 10 days of positive culture. One hundred seventy BSIs were diagnosed in 100 patients (27%): 80 (47%) MBI-LCBIs, 68 (40%) CLABSIs, and 22 (13%) secondary infections. MBI-LCBIs were diagnosed at a significantly higher rate in allogeneic HSCT patients (18% versus 7%, P = .007). Reduced-intensity conditioning (OR, 1.96; P = .015) and transplant-associated thrombotic microangiopathy (OR, 2.94; P = .0004) were associated with MBI-LCBI. Nearly 50% of all patients with a BSI developed septic shock, 10% died within 10 days of positive culture, and nearly 25% were transferred to the PICU. One-year NRM was significantly increased in patients with 1 (34%) and more than 1 (56%) BSIs in the first year post-HSCT compared with those who did not develop BSIs (14%) (P ≤ .0001). There was increased 1-year NRM in patients with at least 1 MBI-LCBI (OR, 1.94; P = .018) and at least 1 secondary BSI (OR, 2.87; P = .0023) but not CLABSIs (OR, 1.17; P = .68). Our data demonstrate that MBI-LCBIs lead to substantial use of healthcare resources and are associated with significant morbidity and mortality. Reduction in frequency of MBI-LCBI should be a major public health and scientific priority.

A Prospective, Holistic, Multicenter Approach to Tracking and Understanding Bloodstream Infections in Pediatric Hematology-Oncology Patients

“…11 The recognition that the dogma "BSIs are CL-associated unless proven otherwise" was not a good fit for specialty populations (eg, PHO patients) led to defining a new category of MBI-LCBI in January 2013 16 and to plans for removing those infections from the CLABSI category. When MBI-LCBIs are no longer counted as CLABSIs, the CLABSI rate in PHO patients will, based on our data and similar results by others, [16][17][18][19] drop by at least 50%. This decrease may remove CLABSIs from the spotlight, but it makes them no less clinically meaningful or important to prevent.…”

Bacterial bloodstream infections in the allogeneic hematopoietic cell transplant patient: new considerations for a persistent nemesis

“…Risk factors for BSI include age greater than 18 years, use of unrelated graft source and myeloablative conditioning regimen, acute GvHD, mucositis, transplant-associated thrombotic microangiopathy (TA-TMA), high-risk malignant disease and steroid use 5,22 (Figure 2). …”

“…The intestine can also be a target of TA-MA, potentially leading to bacterial translocation and interestingly, TA-TMA is strongly associated with MBI-LCBI. 5 Patients with TA-TMA might benefit from preventative strategies to reduce MBI-LCBI.…”

“…20 In pediatric populations, non-malignant diseases are associated with higher BSI risk than malignant diseases. 5,35 …”

“…[4][5][6] Central line-associated bloodstream infections (CLABSIs) are serious complications in HCT recipients and lead to prolonged hospitalization, and intensive care admissions. [4][5][6][7] According to National Healthcare Safety Network (NHSN) data, CLABSI incidence continues to be highest in the HCT population, wherein rates are higher than in any other high-risk population, including solid organ transplant and burn patients, or care setting (that is, intensive care units). 8 This paper will review the impact of bacterial BSI in the current transplant period as measured by resource utilization and associated morbidity and mortality in allo-HCT patients.…”