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  Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 53  |  Issue : 4  |  Page : 590-591
 

Spectrum of bacteremia in posthematopoietic stem cell transplant patients from an Indian center


1 Department of Infectious Diseases, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
2 Department of Onco Haematology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
3 Department of Oncology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India

Date of Web Publication21-Apr-2017

Correspondence Address:
A Ghafur
Department of Infectious Diseases, Apollo Speciality Hospital, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.204766

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 » Abstract 

BACKGROUND: Despite the relatively low prevalence of Gram-positive bacteremic infections in Indian oncology patients, glycopeptides are extensively used for empirical management of febrile neutropenia. Our aim was to analyze the spectrum of bacteremia in posthematopoietic stem cell transplant (HSCT) recipients in our center and make a recommendation on glycopeptide use in this patient population. MATERIALS AND METHODS: Retrospective analysis of bacteremic data from HSCT recipients in a tertiary care oncology and transplant center from South India, between 2011 and 2013. RESULTS: In 217 patients, 52 bacteremic episodes were identified. The majority of the isolates were Gram-negatives (88.4%) with very few Gram-positives (7.69%). CONCLUSION: Glycopeptides need not be included in the empirical antibiotic regimen in post-HSCT settings with very low Gram-positive infection rates.


Keywords: Bacteremia, glycopeptide, hematopoietic stem cell transplant


How to cite this article:
Ghafur A, Devarajan V, Raj R, Easow J, Raja T. Spectrum of bacteremia in posthematopoietic stem cell transplant patients from an Indian center. Indian J Cancer 2016;53:590-1

How to cite this URL:
Ghafur A, Devarajan V, Raj R, Easow J, Raja T. Spectrum of bacteremia in posthematopoietic stem cell transplant patients from an Indian center. Indian J Cancer [serial online] 2016 [cited 2019 Aug 24];53:590-1. Available from: http://www.indianjcancer.com/text.asp?2016/53/4/590/204766



 » Introduction Top


Blood stream infections (BSIs) represent one of the most common bacterial infections in hematopoietic stem cell transplant (HSCT) recipients.[1] The spectrum and incidence of bacteremia vary among different patient risk groups and geographic regions.[1],[2] Bacteremia can occur in 5–10% of autologous and 20–30% of allogeneic HSCT patients.[1] Most Western centers have reported a predominance of Gram-positive bacteria over Gram-negatives as the cause of BSI.[1],[2],[3],[4],[5],[6] The pattern is very different in South Asia, with Gram-negative dominance, in nononcology as well as oncology patients.[7],[8]

Local epidemiology is extremely important while selecting empirical antibiotic regimen for patients with febrile neutropenia. Inclusion of glycopeptides is very common in the empiric antibiotic regimen of febrile neutropenics, including post-HSCT patients. If the prevalence of Gram-positive infection, especially bacteremic infection is low in Indian scenario, we can very well reduce the usage of glycopeptides. Unfortunately, there are limited Indian data in this highly selective post-HSCT population. Our aim was to analyze the spectrum of bacteremia in post-HSCT patients in our center.


 » Materials and Methods Top


We conducted a retrospective analysis of bacteremic data from patients who underwent HSCT (autologous, allogeneic, or cord blood) in a tertiary care oncology and transplant center from South India, between 2011 and 2013. Identification of the isolates was done using VITEK ® 2 compact autoanalyzer (BioMérieux, France), as per the corresponding Clinical and Laboratory Standards Institute guidelines.


 » Results Top


There were 217 bone marrow transplants in the above-mentioned period and 52 bacteremic episodes (23.9%). Out of these, 46 (88.4%) were Gram-negative organisms (23 Enterobacteriaeae and 23 nonfermenters) and 4 were Gram-positive organisms (1 Enterococcus, 1 Gemella, 1 Streptococcus mitis, and 1 Staphylococcus hominis). Among the Enterobacteriaceae, there were 17 Klebsiella and 6 Escherichia coli isolates. Out of the nonfermenter isolates, there were 12 Pseudomonas, 7 Ochrobacter anthropi, 1 Elizabethkingia meningoseptica, 1 Ralstonia, 1 Aeromonas, 1 Stenotrophomonas, and 1 Moraxella. Out of 52 bacteremic isolates, only 4 (7.69%) were due to Gram-positive organisms.


 » Discussion Top


Bacteremia is a common complication in post-HSCT patients, with allogeneic HSCT patients having a higher risk than patients who have autologous HSCT.[1] Mucositis and presence of central venous catheters are the predominant risk factors during preengraftment phase. Graft versus host disease and central venous catheters are the main predisposing factors during the postengraftment phase. Bacteremia is more common during preengraftment phase than postengraftment phase.[1]

At global level, there was a significant shift in the spectrum of bacteremia from Gram-negatives to Gram-positives in the early part of the last decade, probably due to the increased use of indwelling lines and the practice of administering prophylaxis against Gram-negatives.[2] The trend changed during the later part of the decade with the rate of Gram-negatives on the rise, though at varying levels in different centers.[1],[9] Despite this shift in pattern, Gram-positives still predominate or at least comprise a significant percentage of the bacteremic isolates in the West.[9] This high prevalence has led to the recommendation of initiation of empirical glycopeptides in febrile neutropenics by major guidelines prepared in the West such as IDSA and ECIL; especially for those patients with hypotension or shock, known colonization with methicillin-resistant Staphylococcus aureus (MRSA) or penicillin-resistant Pneumococcus, clinically suspected serious catheter-related infection (cellulitis), and in institutions with high prevalence of MRSA and penicillin-resistant Streptococcus viridans infections.[9] Unfortunately, the practice of using glycopeptides is a common practice in Indian oncology centers, mostly influenced by the Western guidelines. One of the main reasons for this dependence on glycopeptide could be a lack of published data on the Gram-negative predominance, from post-HSCT set up in India; despite having a plethora of data in nononcology patients. Our data underscore the very low prevalence of Gram-positives in post-HSCT patients, at least in our center and possibly in other bone marrow transplant centers in India. Febrile neutropenia protocol in our hospital does not recommend prophylactic antibiotics against Gram-positive or Gram-negative bacteria and hence the low prevalence of Gram-positive bacteremia is not due to the administration of prophylactic antibiotics. An antibiotic policy for oncology and post-HSCT patients in India and other South Asian countries, based on local epidemiology is the need of the hour. The strategy of “think global and act local” will be greatly applicable to the highly vulnerable post-HSCT patient population.


 » Conclusion Top


Bacteremic infections in our post-HSCT setting were predominantly due to Gram-negative organisms. These data have an important clinical implication, as glycopeptides need not be included in the empirical antibiotic regimen in settings with very low Gram-positive infection rates.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Balletto E, Mikulska M. Bacterial infections in hematopoietic stem cell transplant recipients. Mediterr J Hematol Infect Dis 2015;7:e2015045.  Back to cited text no. 1
    
2.
Ramphal R. Changes in the etiology of bacteremia in febrile neutropenic patients and the susceptibilities of the currently isolated pathogens. Clin Infect Dis 2004;39 Suppl 1:S25-31.  Back to cited text no. 2
    
3.
Winston DJ, Lazarus HM, Beveridge RA, Hathorn JW, Gucalp R, Ramphal R, et al. Randomized, double-blind, multicenter trial comparing clinafloxacin with imipenem as empirical monotherapy for febrile granulocytopenic patients. Clin Infect Dis 2001;32:381-90.  Back to cited text no. 3
    
4.
Feld R, DePauw B, Berman S, Keating A, Ho W. Meropenem versus ceftazidime in the treatment of cancer patients with febrile neutropenia: A randomized, double-blind trial. J Clin Oncol 2000;18:3690-8.  Back to cited text no. 4
    
5.
Del Favero A, Menichetti F, Martino P, Bucaneve G, Micozzi A, Gentile G, et al. A multicenter, double-blind, placebo-controlled trial comparing piperacillin-tazobactam with and without amikacin as empiric therapy for febrile neutropenia. Clin Infect Dis 2001;33:1295-301.  Back to cited text no. 5
    
6.
Cordonnier C, Buzyn A, Leverger G, Herbrecht R, Hunault M, Leclercq R, et al. Epidemiology and risk factors for gram-positive coccal infections in neutropenia: Toward a more targeted antibiotic strategy. Clin Infect Dis 2003;36:149-58.  Back to cited text no. 6
    
7.
Puri S, Bery A, Sekhon JS, Amandeep. Pattern of infections in patients with neutropenia and their outcome. JIMSA 2010;23:219-21.  Back to cited text no. 7
    
8.
Prabhash K, Medhekar A, Ghadyalpatil N, Noronha V, Biswas S, Kurkure P, et al. Blood stream infections in cancer patients: A single center experience of isolates and sensitivity pattern. Indian J Cancer 2010;47:184-8.  Back to cited text no. 8
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9.
Mikulska M, Viscoli C, Orasch C, Livermore DM, Averbuch D, Cordonnier C, et al. Aetiology and resistance in bacteraemias among adult and paediatric haematology and cancer patients. J Infect 2014;68:321-31.  Back to cited text no. 9
    




 

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