Is it time to reconsider prophylactic antimicrobial use for hematopoietic stem cell transplantation? a narrative review of antimicrobials in stem cell transplantation

ABSTRACT

Introduction

Hematopoietic Stem Cell Transplantation (HSCT) is a life-saving procedure for multiple types of hematological cancer, autoimmune diseases, and genetic-linked metabolic diseases in humans. Recipients of HSCT transplant are at high risk of microbial infections that significantly correlate with the presence of graft-versus-host disease (GVHD) and the degree of immunosuppression. Infection in HSCT patients is a leading cause of life-threatening complications and mortality.

Areas Covered

This review covers issues pertinent to infection in the HSCT patient, including bacterial and viral infection; strategies to reduce GVHD; infection patterns; resistance and treatment options; adverse drug reactions to antimicrobials, problems of antimicrobial resistance; perturbation of the microbiome; the role of prebiotics, probiotics, and antimicrobial peptides. We highlight potential strategies to minimize the use of antimicrobials.

Expert Opinion

Measures to control infection and its transmission remain significant HSCT management policy and planning issues. Transplant centers need to consider carefully prophylactic use of antimicrobials for neutropenic patients. The judicious use of appropriate antimicrobials remains a crucial part of the treatment protocol. However, antimicrobials’ adverse effects cause microbiome diversity and dysbiosis and have been shown to increase morbidity and mortality.

KEYWORDS:

• Bone marrow transplantation (BMT)
• hematopoietic stem cell transplant (HSCT)
• graft-versus-host-disease (GVHD)
• antimicrobial prophylaxis
• antimicrobial resistance
• microbiome
• probiotics

ARTICLE HIGHLIGHTS

• Microbial infections remain a leading cause of mortality in patients undergoing HSCT to treat cancer, autoimmune diseases, and genetic-linked metabolic diseases

• The emergence of antimicrobial-resistant pathogens in HSCT patients is higher than the general hospital population

• The use of prophylactic antimicrobials in HSCT patients, although part of many standard protocols, is controversial. Although successfully eradicating pathogens, the resultant disturbance of the microbiome and the induction of antimicrobial resistance may contribute to higher morbidity and mortality in the long term.

• A healthy gut microbiome not only helps HSCT patients to fight infection but also assists their rapid recovery.

Acknowledgments

The authors are grateful to Prof. Mohammed S. Razzaque, MBBS, Ph.D. of Lake Erie College of Osteopathic Medicine (Pennsylvania, USA), for providing useful suggestions.

Authors’ Contributions

Substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data: DJ, EP, MAS, SI, SP, PS, KI, SD, JC, TCH, NS, TSC, SD, MH; Drafting the article or revising it critically for valuable intellectual content: DJ, EP, MAS, SI, SP, PS, KI, SD, JC, TCH, NS, TSC, SD, MH; Final approval of the version to be published: DJ, EP, MAS, SI, SP, PS, KI, SD, JC, TCH, NS, TSC, SD, MH; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: DJ, EP, MAS, SI, SP, PS, KI, SD, JC, TCH, NS, TSC, SD, MH; Project administration: DJ, EP, MAS, SI, SP, PS, KI, SD, JC, TCH, NS, TSC, SD, MH.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.