Vancomycin-resistant enterococcus infection in the hematopoietic stem cell transplant recipient: an overview of epidemiology, management, and prevention
Abstract:Vancomycin-resistant
enterococcus (VRE) is now one of the leading causes of nosocomial infections in the United States. Hematopoietic stem cell transplantation (HSCT) recipients are at increased risk of VRE colonization and infection. VRE has emerged as a major cause of bacteremia in this population, raising important clinical questions regarding the role and impact of VRE colonization and infection in HSCT outcomes as well as the optimal means of prevention and treatment. We review here the published literatu… Show more
“…Infections caused by enterococci (especially VRE strains) are major problems worldwide (1–4). VRE strains, particularly in immunocompromised patients, are a major and steadily increasing cause of bacteremia (5). VRE bloodstream infections ( VRE-BSI ) rank as one of the top four major infections among hospitalized patients (5).…”
Section: Textmentioning
confidence: 99%
“…VRE strains, particularly in immunocompromised patients, are a major and steadily increasing cause of bacteremia (5). VRE bloodstream infections ( VRE-BSI ) rank as one of the top four major infections among hospitalized patients (5). Commonly used antimicrobial agents used to treat VRE-BSI infections, such as daptomycin, oritavancin, dalbavancin, quinupristin-dalfopristin, and tigecycline, each have a number of important side effects, both acutely and more long-term (2).…”
Tedizolid (
TZD
) is an oxazolidinone derivative which demonstrates bacteriostatic activity through inhibition of protein synthesis. We compared the efficacies of TZD and an earlier-generation oxazolidinone, linezolid (
LZD
), in an experimental murine model of bacteremia caused by two VRE strains (one each
E. faecium
and
E. faecalis
). LZD exhibited significantly better efficacy in terms of reduced VRE blood and target tissue densities than TZD in this model.
“…Infections caused by enterococci (especially VRE strains) are major problems worldwide (1–4). VRE strains, particularly in immunocompromised patients, are a major and steadily increasing cause of bacteremia (5). VRE bloodstream infections ( VRE-BSI ) rank as one of the top four major infections among hospitalized patients (5).…”
Section: Textmentioning
confidence: 99%
“…VRE strains, particularly in immunocompromised patients, are a major and steadily increasing cause of bacteremia (5). VRE bloodstream infections ( VRE-BSI ) rank as one of the top four major infections among hospitalized patients (5). Commonly used antimicrobial agents used to treat VRE-BSI infections, such as daptomycin, oritavancin, dalbavancin, quinupristin-dalfopristin, and tigecycline, each have a number of important side effects, both acutely and more long-term (2).…”
Tedizolid (
TZD
) is an oxazolidinone derivative which demonstrates bacteriostatic activity through inhibition of protein synthesis. We compared the efficacies of TZD and an earlier-generation oxazolidinone, linezolid (
LZD
), in an experimental murine model of bacteremia caused by two VRE strains (one each
E. faecium
and
E. faecalis
). LZD exhibited significantly better efficacy in terms of reduced VRE blood and target tissue densities than TZD in this model.
“…As described above, the patient was at risk for VRE bacteremia because he was admitted to an ICU, had cancer, and was known to be colonized with VRE . A recent review identifies VRE as a leading cause of bloodstream infections in allogeneic stem cell transplant patients . While this occurs most commonly in the early posttransplant period, VRE bacteremia has also been described in stem cell transplant recipients with relapsed hematologic malignancy …”
BACKGROUND: Vancomycin-resistant enterococci (VRE) are antibiotic-resistant organisms associated with both colonization and serious life-threatening infection in health care settings. Contamination of platelet concentrates (PCs) with Enterococcus can result in transfusion-transmitted infection.CASE PRESENTATION: This report describes the investigation of a septic transfusion case involving a 27-year-old male patient with relapsed acute leukemia who was transfused with a 5-day-old buffy coat PC pool and developed fever and rigors.DISCUSSION: Microbiology testing and pulse-field gel electrophoresis (PFGE) was done on patient blood cultures obtained from peripheral and central lines. Microbiology and molecular testing were also performed on the remaining posttransfusion PC pool, which was refrigerated for 24 hours before microbiology testing. Red blood cell (RBC) and plasma units associated with the implicated PCs were screened for microbial contamination. Patient blood cultures obtained from peripheral and central lines yielded vancomycin-resistant Enterococcus faecium. Gram stain of a sample from the platelet pool was negative but coagulase-negative Staphylococcus (CNST) and VRE were isolated on culture. Antibiotic sensitivity and PFGE profiles of several VRE isolates from the patient before and after transfusion, and the PC pool, revealed that all were closely related. Associated RBC and plasma components tested negative for microbial contamination.
CONCLUSIONS: Microbiological and molecularinvestigations showed a relationship between VRE isolated from the patient before and after transfusion, and therefore it is postulated that a patient-to-PC retrograde contamination (from either blood or skin) occurred. As the CNST isolated from the PC pool was not isolated from patient samples, its implication in the transfusion event is unknown. V ancomycin-resistant enterococci (VRE), which comprise the species Enterococcus faecium and Enterococcus faecalis, are health care-associated antibiotic-resistant organisms implicated in both serious life-threatening infection and human colonization and environmental contamination. 1-3 Patients with VRE bacteremia are at greater risk for longer hospital stay and mortality than patients with bacteremia caused by vancomycin-susceptible enterococci. 4 Patients at highest risk for VRE bacteremia include those admitted to an ABBREVIATIONS: CNST = coagulase-negative Staphylococcus; ICU = intensive care unit; PCs = platelet concentrates; PFGE = pulse-field gel electrophoresis; RSV = respiratory syncytial virus; VRE = vancomycin-resistant enterococci. From the
“…Reports from other transplant centers show similar rates of colonization, but are more discordant with respect to the rates of VRE conversion from colonization to bacteremia, depending largely upon patient risk factors. Interestingly, others have found VRE colonizers are not only at higher risk for VRE bacteremia, but also possibly bacteremia from other organisms ( Benamu & Deresinski, 2018 ; Ford et al, 2017 ; Webb et al, 2017 ).…”
Most patients who undergo hematopoietic stem cell transplantation develop neutropenic fever and are at high risk for developing potentially life-threatening infections. β-lactam antibiotics remain the cornerstone for initial empiric treatment of neutropenic fever. In cancer patients with allergy or intolerance to β-lactams, guidelines recommend using aztreonam with vancomycin (AV) for neutropenic fever treatment. To date, the efficacy of AV for the treatment of neutropenic fever during stem cell transplantation is unknown. A retrospective study was conducted to identify hematopoietic stem cell transplantation recipients who were initially treated with concomitant AV for neutropenic fever between 2007 and 2013. Febrile neutropenia was classified as neutropenia with unexplained fever, neutropenic fever with a local source of infection, or neutropenic fever with a microbiologically documented infection. Seventy-six patients were identified who received AV as initial treatment for neutropenic fever over the study period. Responses to AV for neutropenia with unexplained fever (n = 41), febrile neutropenia with local site of infection (n = 11 [pneumonia = 9, other = 2]), and neutropenic fever with microbiologically documented infection (n = 34) were 75%, 55% (45% pneumonia), and 46% respectively. Infection-related mortality was 5%. Aztreonam with vancomycin was effective in treating neutropenia with unexplained fever. For patients with neutropenic fever and local source or microbiologically documented infection, alternative antibiotic treatments should be considered.
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