Limited Utility of Outpatient Surveillance Blood Cultures in Hematopoietic Cell Transplant Recipients on High-Dose Steroids for Treatment of Acute Graft-versus-Host-Disease
Limited Utility of Outpatient Surveillance Blood Cultures in Hematopoietic Cell Transplant Recipients on High-Dose Steroids for Treatment of Acute Graft-versus-Host-Disease
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DOI：
10.1016/j.bbmt.2019.01.031
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发表时间：
2019-06-01
影响因子：
4.3
通讯作者：
Pergam, Steven A.
中科院分区：
文献类型：
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作者：
Stohs, Erica;Chow, Victor A.;Pergam, Steven A.
用于治疗急性移植物抗宿主病(GVHD)的类固醇被认为可以减轻感染的临床症状。我们的目的是评估从接受大剂量类固醇治疗的造血细胞移植(HCT)患者的门诊环境中每周监测血培养(SBCs)的价值。我们假设，大多数阳性的门诊监测细菌将是低致病性、革兰氏阳性细菌，并将导致过量的万古霉素治疗。我们对2009年4月至2013年5月期间参加大剂量激素(相当于5 mg/kg/天的泼尼松)急性移植物抗宿主病(GVHD)治疗的成年HCT患者的血培养进行了回顾性研究。SBCs被定义为在患者接受大剂量类固醇治疗时，在门诊环境中每周从中心静脉导管收集的SBCs。作为症状检查的一部分或作为记录的菌血症的随访而获得的培养被排除在外。使用中心数据库收集临床数据，并辅之以病历审查。127名接受HCT的患者符合纳入研究的条件。总共获得了1015个SBCs，每个患者的中位数为8个培养(四分位数范围为5到10个)。从30名患者的1015份培养中的36份中分离出42株细菌(3.5%)，或每28份血培养中有1份阳性培养。最常见的细菌是凝固酶阴性葡萄球菌(25/1015[2.5%])。革兰氏阴性菌很少见(4/1015[0.4%])。大多数监测培养阳性的患者使用了抗生素(33/36[92%])。其中6人入院接受治疗，无人需要重症监护或死于菌血症。万古霉素是最频繁使用的抗生素，在队列接受抗生素的376天中有256天(68%)，中位持续时间为10天(四分位数范围从7到14)。每周从无症状、大剂量糖皮质激素治疗同种异体HO‘后急性移植物抗宿主病(GVHD)患者身上获得的SBCs很少见阳性，且大多数细菌为低致病力细菌。SBCS还导致了过量的抗生素暴露和成本，这表明这种动态筛查的好处在这种情况下可能价值有限。(C)2019年美国血液和骨髓移植学会。
Steroids used to treat acute graft-versus-host-disease (GVHD) are believed to blunt clinical symptoms of infection. We aimed to assess the value of weekly surveillance blood cultures (SBCs) drawn in an outpatient setting from hematopoietic cell transplant (HCT) patients receiving high-dose steroids. We hypothesized that most positive outpatient surveillance cultures would be low-pathogenicity, gram-positive organisms and would lead to excess vancomycin therapy. We conducted a retrospective review of blood cultures collected from a cohort of adult HCT patients enrolled in a clinical trial of acute GVHD therapy with high-dose steroids (prednisone-equivalent doses >= 5 mg/kg/day) between April 2009 and May 2013. SBCs were defined as those collected weekly from central venous catheters in the outpatient setting while patients were receiving high-dose steroids. Cultures obtained as part of a symptom workup or as follow-up for documented bacteremia were excluded. Clinical data were collected using center databases supplemented by medical record review. One hundred twenty-seven HCT recipients were eligible for inclusion in the study. A total of 1015 SBCs were obtained, with a median of 8 cultures (interquartile range, 5 to 10) per patient. Forty-two organisms were isolated from 36 of 1015 cultures (3.5%) in 30 unique patients, or 1 positive culture per 28 blood cultures drawn. The most frequently detected organisms were coagulase-negative Staphylococci (25/1015 [2.5%]). Gram-negative organisms were rare (4/1015 [.4%]. Antibiotics were administered to most patients with positive surveillance cultures (33/36 [92%]). Six were admitted to the hospital for treatment; none needed intensive care or died from their bacteremia. Vancomycin was the most frequently administered antibiotic, comprising 256 of 376 total days (68%) of antibiotic received by the cohort with a median duration of 10 days ((interquartile range, 7 to 14). Weekly outpatient SBCs obtained from asymptomatic patients on high-dose glucocorticoids for treatment of acute GVHD after allogeneic HO' were infrequently positive, and most organisms were low-pathogenicity organisms. SBCs also led to excess antibiotic exposure and costs, suggesting benefits of such ambulatory screening may be of limited value in this setting. (C) 2019 American Society for Blood and Marrow Transplantation.