Clinical Scorecard: Bacterial Bloodstream Infections in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation: Emerging Insights into a Persistent Challenge

At a Glance

Key Highlights

• BSIs are a leading cause of morbidity and mortality post-allo-HCT, increasing hospitalization, ICU admissions, and non-relapse mortality.
• CLABSI rates remain highest in allo-HCT patients compared to other high-risk populations; MBI-LCBI represents BSIs related to mucosal barrier injury rather than catheter infection.
• Risk factors for BSI include pre-engraftment neutropenia, mucositis, CVC presence, acute and chronic GvHD, steroid use, and high-risk disease status.

Guideline-Based Recommendations

Diagnosis

• Classify BSIs as primary (CLABSI or MBI-LCBI) or secondary based on source identification.
• Use differential time-to-positivity between blood cultures from CVC and peripheral sites to diagnose catheter-related bloodstream infection (CRBSI).
• Apply NHSN definitions for surveillance and IDSA criteria for clinical diagnosis of CRBSI.

Management

• Implement improved central venous catheter maintenance to reduce CLABSI rates.
• Recognize that MBI-LCBI prevention requires strategies beyond catheter care, addressing mucosal barrier injury.
• Consider patient-specific risk factors such as immunosuppression and graft source in antimicrobial prophylaxis and therapy.

Monitoring & Follow-up

• Surveillance of BSI incidence using NHSN definitions including CLABSI and MBI-LCBI categories.
• Monitor for early signs of infection especially during pre-engraftment and in patients with GvHD post-engraftment.
• Track antimicrobial resistance patterns and emerging pathogens in allo-HCT populations.

Risks

• Increased risk of BSI with age >18 years, unrelated grafts, myeloablative conditioning, acute and chronic GvHD, mucositis, TA-TMA, steroid use, and high-risk malignancy.
• BSIs contribute to higher non-relapse mortality and prolonged hospitalization.
• Post-engraftment BSIs are associated with poorer outcomes and higher fatality rates.

Patient & Prescribing Data

Adults and pediatric patients undergoing allo-HCT

Bacterial infections occur in over 50% of patients within one year post-transplant, with higher incidence after mismatched unrelated donor grafts; antibacterial prophylaxis and immunosuppression influence BSI risk.

Clinical Best Practices

• Maintain rigorous central venous catheter care protocols to reduce CLABSI incidence.
• Distinguish between CLABSI and MBI-LCBI to tailor prevention and treatment strategies appropriately.
• Assess and mitigate patient-specific risk factors including immunosuppressive therapies and graft characteristics.
• Employ timely and accurate diagnostic methods such as differential time-to-positivity for CRBSI confirmation.
• Monitor infection trends and resistance patterns to guide antimicrobial stewardship in allo-HCT patients.

References

• National Healthcare Safety Network (NHSN) definitions and data
• Infectious Disease Society of America (IDSA) guidelines on catheter-related bloodstream infections
• Mikulska et al. study on timing of BSIs in allo-HCT
• Ballen et al. study on infection incidence post allo-HCT