Bone-Marrow Transplant Recipients
Risk Factors
The degree and duration of neutropenia caused by myeloablative chemotherapy constitute the major risk factor for fungal infection in bone-marrow transplant (BMT) recipients. Cell-mediated immunity, in particular T-lymphocyte function, may be impaired by immunosuppressive agents. Allogeneic bone-marrow recipients are at higher risk than are autologous marrow recipients, due primarily to the high risk of graft versus host disease (GVHD) [26]. Mucositis, neutropenia, and antibiotic use are the major risk factors before engraftment. After engraftment, corticosteroids, acute GVHD, and CMV infection predispose the patient to a second, more significant risk period in which immune defenses are suppressed [19, 27].
Incidence and Mortality
In one series, fungal infections were found in 26% of 85 autopsies in BMT recipients [28]. The incidence of fungal infections increased dramatically with duration of neutropenia: 21% in BMT recipients whose neutropenia lasted less than 3 weeks, compared with 57% in patients who were neutropenic for 6 weeks or more [29]. Systemic candidal infections have been reported in approximately 12% of BMT recipients, with 25% mortality directly attributed to the infection [30]. A review in one transplant center noted a decrease in 1-year cumulative incidence of candidiasis before and after institution of fluconazole prophylaxis, decreasing from 11.4% to 4.6% [19]. Invasive aspergillosis has become a leading cause of death after allogeneic BMT, particularly in patients with GVHD [31]. A large retrospective study at the Fred Hutchinson Cancer Research Center between 1987 and 1993 revealed that the incidence of aspergillosis increased from 5.7% to 11.2% during the study [27]. The 1-year mortality in patients with invasive disease was 95%. More recent data from this center have documented a sustained increase in incidence subsequent to 1993, with 3-fold increased incidence in both allogeneic and transplant recipients [32].
Course Number: V035B.043001
This CME Expires on July 1, 2003; no tests will be accepted after this date.
This course is accredited by
The University of Pittsburgh School of Medicine, Center for Continuing Education
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