Influence of protective isolation on outcome of allogeneic bone marrow transplantation for leukemia

Summary:After myeloablative treatment and allogeneic stem cell transplantation (ASCT), patients are kept isolated in the hospital to prevent infections during neutropenia. To date, 22 patients have been given the choice of being treated at home. Eleven could not be treated at home, and they served as controls. Most had haematological malignancies. The donors were 12 HLA-compatible unrelated, nine HLA-identical siblings and one twin. In the home care group, three developed bacteraemia, compared to nine in the controls (P Ͻ 0.01). Patients in the home care group had fewer days of total parenteral nutrition (median 3 vs 24, P Ͻ 0.001), required fewer erythrocyte transfusions (median 4 vs 8, P = 0.01), fewer days on i.v. antibiotics (median 6 vs 13 days), and on analgesics (median 0 vs 15) than the controls (P Ͻ 0.05). Days with fever, time to engraftment, days with G-CSF and acute GVHD were the same in the two groups. Seven of 11 patients treated at home were readmitted to the ward for a median of 3 (0-7) days, due to fever or lack of a caregiver at home. Days to discharge to the out-patient clinic were faster in the group treated at home (median 20 vs 35 days, P Ͻ 0.01). Patients who were treated at home enjoyed being active and taking a walk when they felt like it. This preliminary report suggests that home care after ASCT is not only safe, but superior to isolation in the hospital. Bone Marrow Transplantation (2000) 26, 1057-1060.

Section: Discussionmentioning

confidence: 99%

Is it safe to treat allogeneic stem cell transplant recipients at home during the pancytopenic phase? A pilot trial

Bjurman

et al. 2000

“…Although more recent publications have alluded to the potential detrimental effects of nosocomial infections in hospital settings when the OP program was established in 1995, there was strong support for the use of environmental infection control measures to minimize infections in HSCT recipients. [22][23][24][25] The literature suggested the use of laminar air flow units, patient isolation units, prophylactic antibiotics, anti-microbial contamination and low-microbial diets improved survival among patients. Despite this trend, our OP program was established without the use of any of these environmental controls.…”

Section: Discussionmentioning

confidence: 99%

Performing allogeneic and autologous hematopoietic SCT in the outpatient setting: effects on infectious complications and early transplant outcomes

McDiarmid

Hutton²,

Atkins

et al. 2009

This retrospective single-center study compared the incidence, spectrum and effect of infections in 1045 consecutive allogeneic (allo) and autologous (auto) hematopoietic SCT (HSCT) performed between 1995 and 2006 in the inpatient (IP) or outpatient (OP) setting. We analyzed 374 allo-HSCT (196 IP and 178 OP) and 671 auto-HSCT (163 IP and 508 OP). The incidence of infection was lower both in auto-OP (25% OP vs 33% IP, P ¼ 0.042) and allo-OP cohorts (42.7% OP vs 55.6% IP, P ¼ 0.012). The mean number of infections per transplant was lower in both auto-OP (0.39 OP vs 0.57 IP, P ¼ 0.05) and in allo-OP cohorts (0.78 OP vs 1.09 IP, P ¼ 0.018). The 100-day non-relapse mortality (NRM) for OP auto-HSCT was 4.72% and for IP 3.95% (P ¼ 0.68). The 100-day NRM for OP allo-HSCT was lower at 14.1% than it was for IP at 22.6% (P ¼ 0.041). Time to onset of first infection and spectrum of infections was similar in all groups. We conclude that performing allo-and auto-HSCT in the OP setting results in short-term outcomes, including infections complications that are comparable to the standard IP setting.

“…1,10,[16][17][18] With focus on neutropenia, strict isolation in sterile units or laminar airflow compartments has been standard care practice for many years. [19][20][21] Improvement in diagnosing infections, availability of better broad spectrum antibiotics, novel antifungal and antiviral agents, introduction of intravenous immunoglobulins and vaccination strategies have changed attitudes. Infections are considered as treatable conditions.…”

mentioning

confidence: 99%

Cause of death after allogeneic haematopoietic stem cell transplantation (HSCT) in early leukaemias: an EBMT analysis of lethal infectious complications and changes over calendar time

Gratwohl

Brand

Frassoni

et al. 2005

Self Cite

241

178

Summary:We analysed a large homogeneous group of 14 403 patients transplanted for early leukaemia from an HLAidentical sibling and reported to the EBMT in four time cohorts : 1980-1989 (24%), 1990-1994 (26%), 1995-1998 (30%) and 1999-2001 (20%). We focused on death from infection. End points were survival, death from relapse and transplant-related mortality (TRM), which was subdivided into death from graft-versus-host disease (GvHD) (1315 patients; 25% of deaths), infection (597 patients; 11% of deaths) or 'other' causes (1875 patients; 34% of deaths). Survival increased from 52% at 5 years in the first to 62% in the third cohort (Po0.05) and TRM decreased from 36 to 26% (Po0.05) due to a reduction in death from infection (Po0.001). GvHD, 'other' causes and relapse did not improve. The relative proportions of bacteria (217 patients; 36%), viruses (183 patients; 31%), fungi (166 patients; 28%) or parasites (32 patients; 5%) as cause of infectious death (cumulative incidence of death at 5 years 1.8, 1.6, 1.4 and X0.3%, respectively) and median time to death from infections (3 months (range 0-158 months)) did not change. Death from infections has been reduced significantly, but it still represents an ongoing risk after HSCT and draws attention to the time beyond the initial period of neutropenia.