Make Sure You Have a Safety Net: Updates in the Prevention and Management of Infectious Complications in Stem Cell Transplant Recipients

Abstract

Hematopoietic stem cell transplant recipients are at increased risk of infection and immune dysregulation due to reception of cytotoxic chemotherapy; development of graft versus host disease, which necessitates treatment with immunosuppressive medications; and placement of invasive catheters. The prevention and management of infections in these vulnerable hosts is of utmost importance and a key "safety net" in stem cell transplantation. In this review, we provide updates on the prevention and management of CMV infection; invasive fungal infections; bacterial infections; Clostridium difficile infection; and EBV, HHV-6, adenovirus and BK infections. We discuss novel drugs, such as letermovir, isavuconazole, meropenem-vaborbactam and bezlotoxumab; weigh the pros and cons of using fluoroquinolone prophylaxis during neutropenia after stem cell transplantation; and provide updates on important viral infections after hematopoietic stem cell transplant (HSCT). Optimizing the prevention and management of infectious diseases by using the best available evidence will contribute to better outcomes for stem cell transplant recipients, and provide the best possible "safety net" for these immunocompromised hosts.

Infectious complications in allogeneic hematopoietic cell transplant recipients: Review of transplant‐related risk factors and current state of prophylaxis

“…There are two main sources of bacterial infections during the early pre‐engraftment phase: gut microflora responsible for gram‐negative infections, and indwelling intravenous access devices responsible mostly for gram‐positive infections. Antibacterial prophylaxis, oral hygiene, neutropenic diet, and gut decontamination decrease the infections rate and chemotherapy‐induced febrile episodes 2,41‐43 …”

“…Infectious complications are a significant cause of morbidity and mortality among allogeneic hematopoietic cell transplant (allotransplant) recipients. The main predisposing factors include pre‐transplant conditioning regimen causing neutropenia, hypogammaglobulinemia, lymphopenia, and mucosal barrier injury 1,2 and graft‐versus‐host disease (GvHD) requiring immunosuppressive treatment which subsequently deepens and prolongs already impaired cellular and humoral immunity 3 …”

Immune Response against Adenovirus in Acute Upper Respiratory Tract Infections in Immunocompetent Children

“…Any condition determining a severe immunosuppression with a lack of cellular activity confers a high risk of invasive and disseminated disease. In particular, patients undergoing allogeneic hematopoietic stem cell transplantation have a greater risk of Adenovirus related complications, resulting from de novo infection or reactivation of persistent endogenous virus [ 15 ]. In recipients of hematopoietic stem cell transplantation, HAdV infections have an incidence of up to 21% and are 2–3.5 times more likely in children compared with adults [ 2 , 15 ].…”

“…In particular, patients undergoing allogeneic hematopoietic stem cell transplantation have a greater risk of Adenovirus related complications, resulting from de novo infection or reactivation of persistent endogenous virus [ 15 ]. In recipients of hematopoietic stem cell transplantation, HAdV infections have an incidence of up to 21% and are 2–3.5 times more likely in children compared with adults [ 2 , 15 ]. The frequency of invasive disease is 8–26%, and, in the case of respiratory tract infections, dissemination and/or severe respiratory failure develops in 10–30% of cases with a fatality rate possible of exceeding 50% [ 2 , 15 ].…”

“…In recipients of hematopoietic stem cell transplantation, HAdV infections have an incidence of up to 21% and are 2–3.5 times more likely in children compared with adults [ 2 , 15 ]. The frequency of invasive disease is 8–26%, and, in the case of respiratory tract infections, dissemination and/or severe respiratory failure develops in 10–30% of cases with a fatality rate possible of exceeding 50% [ 2 , 15 ]. Other conditions predisposing patients to more serious clinical conditions related to HAdV infections are being a recipient of solid organ transplantation, severe combined immunodeficiency syndrome, and acquired immunodeficiencies such as Human Immunodeficiency Virus infection [ 3 , 16 ].…”