Introduction
Hematopoietic stem cell transplant (HSCT) is an important treatment
modality for patients with both benign and malignant hematological
diseases [1].Tremendous advances have occurred in the field of stem cell transplant
with the use of mismatched and haploidentical donors and improved
supportive care to prevent graft versus host disease enabling more
patients to undergo transplant safely. Patients undergoing stem cell
transplant are at an increased risk of bacterial, viral and fungal
infections [2]. Patients have severe neutropenia in the
immediate peri-transplant period and are at highest risk of bacterial
infections [3, 4]. Infection is the most common cause of morbidity
and mortality in patients undergoing transplants [5,6]. There can be several reasons for high rates of
infections in these patients [7]. Bacteremia occurs in as high as 20%
of patients [8].Multiorgan dysfunction and mortality ensues in
complicated cases. Some studies have reported that gram-positive cocci
(GPC) blood stream infections (most commonly coagulase negative
staphylococcus) occur more commonly than gram-negative bacilli (GNB)
infections. However, gram-negative infections contributed to as high as
45% mortality in these patients [9].
Measures to decrease the incidence of infections like isolation, HEPA
filter fitted rooms [10] and gut
decontamination have been used in transplant patients. Antibiotic
prophylaxis with fluoroquinolone has been recommended by the IDSA and
ASCO for patients who are expected to have a profound (< 100
neutrophils/uL) and prolonged neutropenia (> 7
days) [11]. In a recent meta-analysis antibiotic
prophylaxis significantly reduced the all-cause mortality in neutropenic
patients [8]. However, it has been shown to alter the gut
microbiome increasing chance of clostridium difficile
infections [12]. There are concerns regarding subsequent emergence of
fluroquinolone resistance increasing need for therapy with carbapenem
antibiotics. Many authors have argued against using prophylactic
antibiotics and advocate well-structured sepsis care bundles that
focuses on timely identification and treatment of neutropenic
sepsis [13]. There
is also a concern around rising carbapenem resistant enterobacteracae
(CRE) around the world [14].
In this study we evaluate the role of antibiotic prophylaxis in patients
undergoing stem cell transplant at our center.