Impact of Empiric Treatment for Vancomycin-Resistant Enterococcus in Colonized Patients Early after Allogeneic Hematopoietic Stem Cell Transplantation

Abstract

In recent years, vancomycin-resistant Enterococcus (VRE) colonization is being increasingly encountered in transplant recipients, and VRE has become one of the leading causes of bacteremia early after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Data are sparse on the effect of empiric VRE therapy for febrile, neutropenic allo-HSCT recipients colonized with VRE. All allo-HSCT recipients aged 18 years who developed VRE bacteremia (VREB) between 2005 and 2014 were identified and categorized as to whether they received empiric or directed VRE therapy. There were 434 (33%) VRE-colonized and 872 (67%) non-VRE-colonized patients during the study period, and 172 of the 434 (40%) VRE-colonized patients received empiric therapy. There was no significant difference in incidence of VREB among colonized patients who did or did not receive empiric therapy (28 of 172 [16%] vs 55 of 262 [21%]; P = .22). There were 95 patients with VREB, of which the majority (83 of 95; 87%) was known to be VRE-colonized. Of the 95 VREB episodes, 29 (31%) were treated with empiric VRE therapy, whereas 66 (69%) were treated with directed therapy. No significant differences in clinical outcomes, including median duration of bacteremia (2 days vs 2 days; P = .39), recurrent VREB (3 of 29 [10%] vs 5 of 66 [8%]; P = .65), 30-day all-cause mortality (1 of 29 [3%] vs 4 of 66 [6%]; P = .62), or VRE-attributable mortality (1 of 29 [3%] vs 1 of 66 [2%]; P = .55), were observed between the empiric therapy and directed therapy groups. Kaplan-Meier curve analysis showed no significant difference in survival at 30 days in allo-HSCT recipients with VREB who received empiric therapy and those who received directed therapy (97% vs 94%; P = .62). Based on our data, we recommend against empiric use of VRE-active agents for fever and neutropenia in VRE-colonized patients undergoing allo-HSCT.

Microbiology of Bloodstream Infections in Children After Hematopoietic Stem Cell Transplantation: A Single-Center Experience Over Two Decades (1997–2017)

“…In the adult HSCT population, VRE BSI is associated with a worse overall survival; however, mortality is infrequently attributable to the VRE BSI [ 47 ]. Indeed, multiple investigators have shown no benefit in patient outcomes with linezolid as empirical therapy for fever and neutropenia [ 48 , 49 ]. Thus, VRE prevention strategies should be prioritized over simply providing broader empirical therapy.…”

Evaluating Initial Empiric Therapy for Neutropenic Fever in Vancomycin-Resistant Enterococcus-Colonized Patients

“… 15 Kamboj and colleagues retrospectively analyzed 484 VRE-colonized allogeneic HSCT recipients with NPF and found that empiric VRE-directed therapy (extensively linezolid) demonstrated no benefit on clinical outcomes or mortality. 16 …”

“…Our analysis confirms and expands on these findings by providing a more wide-ranging and representative sample of adult malignant hematology and HSCT patients (Lisboa et al included pediatric subjects, while Kamboj et al assessed only those undergoing allogeneic HSCT). 14 , 16 Instead of combining malignant hematology and HSCT patients into one group (Lisboa et al and Bossaer et al), our analysis separates them into distinct arms. 14 , 15 This is an important issue that needs to be thoroughly examined and addressed, as the groups have several significant differences that may produce contrasting results.…”

Epidemiology, treatment and outcomes of bloodstream infection due to vancomycin-resistant enterococci in cancer patients in a vanB endemic setting

“…Others have proposed that VRE BSI may contribute to mortality or may just be a marker for severe underlying disease with conflicting reports on the effectiveness of early empiric therapy [1,4,[24][25][26][27]. It has been reported that in patients with hematological malignancy, rates of severe sepsis within 2 days of VRE BSI can be as high as 36% [6].…”