Blood and Marrow Transplantation Reviews: Volume 12, Issue 3

Introduction: When Is an Ounce of Prevention Better?

by John R. Wingard, MD Editor

Tremendous strides have been made in minimizing the adverse effects of infection after hematopoietic stem cell transplantation (HSCT) over the past several decades. Sequentially, risk factors for various infectious complications have been identified; the nature of deficits in host defenses and their change over time have been characterized; new antimicrobial agents have supplanted older, more toxic, or less efficacious ones; and clinical trials to define the most effective ways to quell morbidity have been conducted. Prevention is intuitively appealing, but in the realm of microbial diseases is fraught with potential danger. The chief hazard is the emergence of drug resistance, which has plagued antimicrobial therapies for decades. Accordingly, infection prophylaxis should be used judiciously: only in settings where the strategy has been found to be effective and offers advantages over other treatment approaches. Moreover, prophylaxis should be monitored over time, because a strategy that is effective one day may become useless the next with the emergence of drug resistance.

Several years ago the Centers for Disease Control and Prevention convened a group of infectious disease and HSCT experts to discuss the threat of infectious morbidity after HSCT and to review what available evidence there was to support various infection prophylaxis strategies. This combined effort represented a unique and important opportunity to codify the state of knowledge and standardize practices. The result was a document endorsed by the American Society for Blood and Marrow Transplantation, the Infectious Disease Society of America, and the Centers for Disease Control and Prevention. It was published as a supplement to Biology of Blood and Marrow Transplantation (2000;7(6a):1-95) and a shorter version was published in Morbidity and Mortality Weekly Report (2000;49(RR-10):1-125). The recommendations are available at the ASBMT Web site (http://www.asbmt.org/policystat/policy.html).

In the proceedings of a symposium presented at the 2002 Tandem Transplant meetings supported through an educational grant by GlaxoSmithKline, Drs. Spitzer and Anderlini briefly review these prevention guidelines. They also present some preliminary data on atovaquone, an agent that has excellent activity against Pneumocystis carinii and offers some toxicity advantages over trimethoprim-sulfamethoxazole. The interchange with the audience in the question-and-answer session is one of the strengths of this symposium proceeding and highlights an important lesson. Just as there are shifts in microbial pathogens and drug sensitivities, prevention guidelines also cannot remain static. There were numerous knowledge gaps in 2000 when the ASBMT/IDSA/CDC guidelines were published and there remain many today. Continued study is necessitated by changing transplantation practices, emerging pathogens, alterations in drug susceptibilities, and new diagnostic testing. New drugs (atovaquone, among others) must be fit into our practice. Novel strategies must be evaluated in clinical trials for advances to continue.

In this issue:

Introduction John R. Wingard, MD

Membership Application

ASBMT News

Symposium Report:New Strategies for the Prevention of Pneumocystis carinii Pneumonia and Other Opportunistic Infections after Stem Cell Transplantation 2002 Tandem BMT Meeting February 2002, Orlando, Florida
Thomas R. Spitzer, MD, Paolo Anderlini, MD

Nonmyeloablative Regimen Allows Peripheral Expansion of Donor T-Cells
Nelson J. Chao, Cong X. Liu, Barbara Rooney, Benny J. Chen, Gwynn D. Long, James J. Vredenburgh, Ashley Morris, Cristina Gasparetto, David A. Rizzieri

GVHD Treatment with Steroids
Margaret L. MacMillan, Daniel J. Weisdorf, John E. Wagner, Todd E. DeFor, Linda J. Burns, Norma K.C. Ramsay, Stella M. Davies, Bruce R. Blazar

Journal Watch

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