Incidence and Outcomes of Bacterial Bloodstream Infections during Acute Graft-versus-Host Disease Involving the Gastrointestinal Tract after Hematopoietic Cell Transplantation

Abstract

Despite the association of acute graft-versus-host disease (aGVHD) and bacterial bloodstream infections (BSIs) in hematopoietic cell transplant (HCT) recipients, relatively little is known about BSIs, specifically during gastrointestinal (GI) tract aGVHD (aGHVD-GI). The purpose of this study was to evaluate the incidence, risk factors, and mortality of BSIs complicating aGVHD-GI. This was a retrospective review of adult HCT recipients with grades I to IV aGVHD-GI between January 2009 and October 2017 at Oregon Health and Sciences University. BSIs occurring within 30 days of onset of aGVHD-GI were included. BSIs were categorized as "clinical" or "surveillance" based on chart review. A subgroup analysis of patients with grade IV aGVHD-GI examined potential BSI risk factors and cumulative survival at 30 and 45 days after onset of aGVHD-GI. Included were 229 patients. There were 45 unique BSIs in 39 patients (17%): 31 clinical (68.9%) and 14 surveillance (32.1%). The median time from aGVHD-GI onset to BSI was 18.5 days. BSIs were significantly more common during grade IV aGVHD-GI compared with grades I, II, or III. Fifty-two organisms were isolated during BSIs: 23 (44.2%) gram-positive and 29 (55.8%) gram-negative. Sixteen BSIs (36%) occurred during antibiotic exposure, and those were more likely to be caused by multidrug-resistant organisms. Prior BSI occurring between the time of HCT and onset of aGVHD-GI and receipt of etanercept for steroid-refractory aGVHD-GI were independently associated with BSI. Eight patients, all with grade IV aGVHD, representing 30.8% of patients with BSI in this subgroup, experienced infection-associated mortality. Cumulative survival at days 30 and 45 after onset of grade IV aGVHD-GI was similar among patients with and without BSI. BSI is a common complication of grade IV aGVHD-GI, resulting in significant infection-associated mortality. Interventions targeting those at highest risk may be warranted.

Keywords: Bacteremia; Bloodstream infection; Graft-versus-host disease; Hematopoietic cell transplant; Infection.