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.