Materials and Methods
This is a retrospective observational study. A total of 219 patients
were included in the study over a period of 2012 to 2019. Patients were
nursed in HEPA filtered air-conditioned single rooms in isolation with
reverse barrier nursing. All persons entering the room used gowns, shoe
covers, face mask and cap, and washed their hands thoroughly or used
antiseptic handwash. The initial 100 patients who underwent HSCT had
received oral antibiotic prophylaxis with oral levofloxacin.
Levofloxacin was started at the time of admission and was continued till
day + 28 and it was similar for both autologous or allogeneic transplant
during the study period. Fluconazole and valacyclovir were given as
antifungal and antiviral prophylaxis, respectively. Fluconazole and
valacyclovir were stopped on day 28. In view of concerns around rising
incidence of CRE in our unit and around the world, antibiotic
prophylaxis was discontinued after first 100 BMTs. At present we stop
antibiotic prophylaxis at the time of neutrophil engraftment. Caps are
no longer used in our transplant unit now.
Fever was defined as a single temperature of ≥ 101 F or
>100.4 F lasting for more than 1 hour.3Any febrile episode was taken as infective episode and treated
accordingly. First-line antibiotic consisted of piperacillin–tazobactam
or cefoperazone-sulbactum and amikacin. This was modified later
depending on microbiological information or clinical evolution. A severe
or life-threatening/fatal infection was defined according to the Blood
and Marrow Transplant Clinical Trials Network criteria [15]. A severe bacterial infection was defined as any bacterial organ
infection and/or bacteremia by any bacterial organism in a febrile
patient [16]. We
analyzed in detail all bacterial infections that occurred in the first
30 days post-transplant that led to the patient’s death.
Hematopoietic stem cell source was peripheral blood and all products
were unmanipulated. Neutrophil engraftment was defined as the first of 3
consecutive days with achievement of absolute neutrophil count of ≥
500/mm3 and no subsequent decline. Platelet engraftment was defined as
the first of 3 consecutive values of platelet count ≥ 20,000/cm3 with
transfusion independence. All patients remained hospitalized until
engraftment and until the time deemed clinically suitable for discharge.
Discharge criteria were neutrophil engraftment, absence of infection and
ability to eat and drink [17]. Primary
objective of study was to identify carbapenem resistant gram negative
infection. Secondary outcome measures included documented infections,
blood stream infections (BSI), incidence of gram positive, gram-negative
sepsis, infection related mortality and duration of hospital stay.