Boeckh, M.

Corey, L.

Leisenring, W.

Pergam, S.

Pollack, M.

Elsevier - Publisher Connector 

Evaluation of a Novel Viral Load Based Surveillance Strategy for Prevention of Cytomegalovirus (CMV) Disease in Hematopoietic Cell Transplantation 

S278 Poster Session IMethods: This retrospective cohort study evaluated patients who
underwent CBT at the Fred Hutchinson Cancer Research Center
(FHCRC) in Seattle, WA between 2006 and 2009. Data were col-
lected from patient medical records and the center’s clinical data-
bases. All IFI were classified as early (# 40 days post-transplant),
late (41-180 days) or very late (181-365 days), and pretransplant in-
fections were not included. Only proven or probable IFIs as defined
by standard criteria were analyzed. Incidence rates were determined
and a priori risk factors for IFI were assessed using chi squared or
Wilcoxon rank-sum analyses where applicable.
Results:A total of 103 CBT recipients were eligible for inclusion in
this study. Median age at time of transplant for the cohort was 30.4
years (interquartile range [IQR] 14, 48), and most patients under-
went myeloablative conditioning (71/103 [69%]) and received
a double cord transplant (88/103[85%]). Overall, 16 patients
(15.5%) developed 19 total IFIs (5 proven, 14 probable) within
the first year posttransplant. Following their primary episode 3 pa-
tients developed a second IFI due to a different fungal pathogen,
and 6 patients had a known pretransplant IFI which were excluded
from analyses. The median onset of first IFI was 65.5 days post-
transplant (IQR 28, 126). The cohort specific incidence rate of
IFI during the first year was 0.92 cases per 1000 patient days
(95% CI 0.56, 1.49). The majority of IFIs occurred during the
high risk early and late periods (both 9/19 [47%]). Invasive Aspergil-
lus was the most common IFI (12/19 [63%]) during the period of
observation, but others included Zygomycetes (3), Scopulariopsis
(1), Fusarium (1) and candidal species (2). Of the 16 patients that de-
veloped at least one IFI, 4/16 (25%) died as a direct result of their
fungal infection. Comparing CBT recipients who did and did not
develop IFI, graft-versus-host disease, time to engraftment, age,
conditioning regimen, and CMV serostatus were not associated
with the development of IFI.
Conclusions: Cord blood transplant recipients appear to be at high
risk for developing postransplant IFIs. Asmost IFIs occurred prior to
day 180 in this cohort, early prevention strategies and the use of
extended-spectrum azole prophylaxis may be needed in this
population.342
EVALUATIONOF A NOVEL VIRAL LOAD BASED SURVEILLANCE STRATEGY
FOR PREVENTION OF CYTOMEGALOVIRUS (CMV) DISEASE IN HEMATO-
POIETIC CELL TRANSPLANTATION
Pollack, M.1,2, Leisenring, W.1, Pergam, S.1,2, Corey, L.1,2, Boeckh, M.1,2
1Fred Hutchinson Cancer Research Center, Seattle, WA; 2University of
Washington, Seattle, WA
Introduction: Surveillance and preemptive therapy for CMV reac-
tivation is the most commonly used strategy to prevent CMV disease
in hematopoietic cell transplant (HCT) recipients. In 2007, our cen-
ter switched from a strategy using pp65 antigenemia testing with
treatment for any level of antigen, to one using quantitative PCR
tests (J. Clin. Microbiol. 42:p1142, 2004), with treatment thresholds
determined by each patient’s disease risk. We hypothesized that
this both sensitive and specific testing strategy would lead to earlier
diagnosis, thereby decreasing the incidence of CMV disease.
Methods: We retrospectively examined two cohorts of patients re-
ceiving their first allogeneic HCT who were either CMV seroposi-
tive (R+) or had a seropositive donor (D+/R-). Patients in the first
cohort (2002-2005, n5 703) received weekly antigen testing and an-
tiviral therapy was initiated for any positive test. Patients in the sec-
ond cohort (2007-2009, n 5 385) were tested by PCR weekly and
received therapy at a DNA level of. 500 copies/ml, unless receiving
$ 1mg/kg of prednisone or anti-T cell therapies in whom therapy
was initiated at a level . 100 copies/ml. Cord blood recipients
were excluded from analyses. Results were analyzed using multivari-
able Cox regression and competing risk regression models including
several pretransplant risk factors.
Results: In a multivariate model, PCR based testing resulted in
a similar overall 1 year mortality (adjusted HR 0.91, 95% CI 0.7-
1.1, p 5 0.38) to antigenemia testing. The cumulative incidence of
CMV disease by day 100 was also similar between the two groups
(aHR 1.25, 95% CI 0.7-2.3, p 5 0.48). Patients who were CMV
R+ pretransplant were more likely to develop CMV disease than
D+/R- patients (aHR 3.3, 95% CI 1.0-10.6, p 5 0.05). While theoverall rates of CMV disease were similar, PCR surveillance was
associated with more gastrointestinal disease and less pneumonia
(RR 0.36, 95% CI 0.08-0.86, p 5 0.02).
Conclusions: We have demonstrated that a preemptive treatment
strategy based on viral load and host risk factors resulted in similar
rates of CMV disease and overall survival compared to an antigene-
mia based strategy. The PCRbased strategywas associatedwith a de-
creased incidence of CMV pneumonia. Future studies are needed to
further examine the characteristics of gastrointestinal CMV disease
in seropositive patients that is not detected by blood based PCR
surveillance.343
SURVEY RESULTS OF IMMUNIZATION PRACTICES FOLLOWING HEMATO-
POIETIC STEM CELL TRANSPLANT AMONG CENTERS IN THE UNITED
STATES
Held, K.1, Smith, S.2, Shreve, N.3, Dalal, J.3, Liewer, S.4 1Children’s
Mercy Hospitals and Clinics, Kansas City, MO; 2The Johns Hopkins
Hospital, Baltimore,MD; 3Children’sMercy Hospitals and Clinics, Kansas
City, MO; 4The Nebraska Medical Center, Omaha, NE
Vaccine immunity declines in recipients following hematopoietic
stem cell transplant (HSCT) placing patients at risk for significant
complications from vaccine-preventable diseases. An international,
collaborative group recently published recommendations to stan-
dardize revaccination of HSCT recipients. The purpose of this study
was to surveyHSCT centers within theUnited States to characterize
current vaccination practices.
Methods: A 25-question web-based survey was distributed six
months after the publication of updated guidelines to administrators
of HSCT centers throughout the United States registered with the
National Marrow Donor Program. All submitted survey responses
were included in the analysis.
Results: Forty-seven of the 124 eligible HSCT centers (38%) com-
pleted the survey. All survey responses were included in the analysis
although only 29 centers (62%) completed the full survey. Thirty-
one centers of 40 responding (78%) developed a standard operating
procedure which addressed revaccination and 38 programs (95%)
followed a standardized vaccination schedule. Approximately half
of the centers reimmunized autologous and allogeneic HSCT recip-
ients on the same schedule and a majority of centers (90%) altered
the vaccination schedule for patients receiving immunosuppression.
Nineteen of 37 responding centers (51%) routinely monitored im-
munologic markers prior to revaccination and thirteen of 29 centers
(45%) utilized the results to modify therapy. Following vaccine
administration, 8 of 37 responding centers (22%) obtained antibody
titers. The updated guideline included changes to administration of
the pneumococcal, diphtheria, tetanus, and acellular pertussis
vaccines and these practices were less consistent with the newly
published recommendations. Immunization practices that closely
followed the updated recommendations included vaccination with
theHaemophilus influenzae type b conjugate vaccine, inactivated polio
and hepatitis B vaccines.
Conclusions:Vaccination practices followingHSCT vary consider-
ably among programs within the United States despite the recent
publication of updated guidelines. Overall, the international recom-
mendations may help to standardize practice and improve patient
outcomes following HSCT. These findings highlight future educa-
tional opportunities for health care providers and the need for addi-
tional research.344
PREVENTION OF INVASIVE MOLD INFECTION POST ALLOGENEIC STEM
CELL TRANSPLANTATION (AlloSCT) IN PEDIATRIC RECIPIENTS USING
THE SEQUENTIAL COMBINATION OF LIPOSOMAL AMPHOTERICIN B (Am-
bisome) FOLLOWED BY MICAFUNGIN (Mycamine)
Small, T.N.1, El-Mallawany, N.1, Duffey, D.1, Bhatia, M.1, Garvin, J.1,
George, D.1, Satwani, P.1, Cairo, M.1,2,3 1Columbia University, Morgan
Stanley Children’s Hospital of New York Presbyterian, New York, NY;
2Columbia University, Morgan Stanley Children’s Hospital of New
York Presbyterian, New York, NY; 3Columbia University, Morgan
Stanley Children’s Hospital of New York Presbyterian, New York, NY


file:///data/core-remote/dit/data/elsevier/pdf/9b3/aHR0cDovL2FwaS5lbHNldmllci5jb20vY29udGVudC9hcnRpY2xlL3BpaS9zMTA4Mzg3OTExMDAwOTQ2OA==.pdf

Evaluation of a Novel Viral Load Based Surveillance Strategy for Prevention of Cytomegalovirus (CMV) Disease in Hematopoietic Cell Transplantation

Abstract

Similar works

Full text

Available Versions

Elsevier - Publisher Connector

Elsevier - Publisher Connector