key: cord-259625-8lripsf7
authors: Piñana, José Luis; Gómez, María Dolores; Montoro, Juan; Lorenzo, Ignacio; Pérez, Ariadna; Giménez, Estela; González‐Barberá, Eva María; Carretero, Carlos; Guerreiro, Manuel; Salavert, Miguel; Sanz, Guillermo; Hernández‐Boluda, Juan Carlos; Borrás, Rafael; Sanz, Jaime; Solano, Carlos; Navarro, David
title: Incidence, risk factors, and outcome of pulmonary invasive fungal disease after respiratory virus infection in allogeneic hematopoietic stem cell transplantation recipients
date: 2019-09-03
journal: Transpl Infect Dis
DOI: 10.1111/tid.13158
sha: 
doc_id: 259625
cord_uid: 8lripsf7

BACKGROUND: There is growing evidence that community‐acquired respiratory virus (CARV) increases the risk of pulmonary invasive fungal disease (IFD) in the allogeneic hematopoietic stem cell transplantation (allo‐HSCT) setting. To date, there is a lack of knowledge regarding the risk factors (RFs), as well as the most critical period for subsequent onset of IFD after CARV infections in allo‐HSCT recipients. METHODS: In this prospective longitudinal observational CARV survey, we analyzed the effect of CARV on subsequent IFD development in 287 adult allo‐HSCT recipients diagnosed with 597 CARV episodes from December 2013 to December 2018. Multiplex PCR panel assays were used to test CARVs in respiratory specimens. FINDINGS: Twenty‐nine out of 287 allo‐HSCT recipients (10%) developed IFD after a CARV episode. The median time of IFD onset was 21 days (range, 0‐158 days) from day of the first CARV detection. Generalized estimating equation model identified 4 risk factors for IFD: ATG‐based conditioning regimen [odds ratio (OR) 2.34, 95% confidence interval (CI) 1.05‐5.2, P = .038], CARV lower respiratory tract disease (OR 10.6, 95% CI 3.7‐30.8, P < .0001), CARV infection during the first year after transplant (OR 5.34, 95% CI 1.3‐21.8, P = .014), and corticosteroids during CARV (OR 2.6, 95% CI 1.1‐6.3, P = .03). CONCLUSION: Allo‐HSCT recipients conditioned with ATG and under corticosteroid therapy at the time of CARV LRTD during the first year after transplant may require close monitoring for subsequent IFD.

Pulmonary invasive fungal disease (IFD) is a relevant cause of morbidity and mortality in the allogeneic hematopoietic stem cell transplantation (allo-HSCT) setting. 1 

IFDs in allo-HSCT [mainly for invasive aspergillosis (IA)] include factors associated with a profound immunosuppressed status, such as duration of neutropenia before engraftment, use and duration of glucocorticosteroid therapy, type of donor, baseline disease, recipient's age, and graft-versus-host disease (GVHD). [2] [3] [4] [5] [6] [7] [8] However, there is growing awareness and evidence that community-acquired respiratory virus (CARV) also increases the risk of IA in immunocompromised and healthy patients, primarily but not limited to influenza infections. 5, [9] [10] [11] [12] [13] [14] [15] Allo-HSCT recipients suffer annual and lifelong exposure to CARV infections; in fact, these infections after allo-HSCT are as common as around 30%. 8, 16 Obviously, not every allo-HSCT recipient with CARV infection has the same risk of developing IFD.

To date, there are limited data regarding the true rate of IFD, the RFs for specific respiratory virus infection, and the most critical period for IFD development after CARV infections in allo-HSCT recipients.

The current study comes from a 5-year prospective longitudinal observational epidemiologic survey of CARV infections and complications in allo-HSCT recipients with upper (URTD) and/or lower respiratory tract disease (LRTD) symptoms after allo-HSCT. We report herein the incidence rate, characteristics, and RFs of IFD in a series of consecutive allo-HSCT recipients after a molecular-proven CARV infection.

We conducted a prospective longitudinal study of CARV infections in adult (>18 years) allo-HSCT recipients at two transplant centers in The CARV survey methodology has previously been described in detail elsewhere. 17, 18 Briefly, at both centers, we developed a prospective CARV survey in allo-HSCT recipients with symptoms suggesting a respiratory virus infection. Irrespective of their transplant date, all recipients with URTD and/or LRTD symptoms were encouraged to undergo a detailed respiratory virus screening through molecular testing. We do not monitor viral shedding negativity after a first detection, except for recipients with active and persistent respiratory symptoms for longer than one month. In such cases, we repeated the PCR test to rule out the acquisition of a new CARV. If the same subtype of CARV was found, we considered as a long-lasting CARV episode.

Clinical and biological variables at the time of CARV PCR testing were prospectively recorded. Variables included transplant characteristics, conditions included in the immunodeficiency scoring index (ISI), 19 hospital admission, immunosuppressant drugs, presence of acute or chronic GvHD, use of antifungal prophylaxis at the time of CARV infection, and subsequent onset of IFD. All allo-HSCT recipients were followed on a regular basis at each transplant center for lifelong. The study protocol was approved by the ethics committee of the Hospital universitari i politècnic La Fe with reference code number 2019/0041.

At HCUV, from January 2013 to February 2014, antifungal prophylaxis was based on voriconazole 200 mg twice daily (BID) from day + 1 to day + 100 and thereafter in cases with active GvHD requiring steroid therapy. From March 2014, antifungal prophylaxis consisted of micafungin (50 mg/day iv) from the start of the conditioning regimen until neutrophil recovery and switched to posaconazole 300mg daily in tablets until day + 100 or while on steroids to treat moderate-to-severe GvHD. At HLF, from January 2010 to December 2016 antifungal prophylaxis was based on fluconazole (100 mg/day) from the start of conditioning until the day of stem cell infusion (day 0) and voriconazole 100 mg/BID a day thereafter until day + 100 or while on steroids. 20 In January 2017, antifungal prophylaxis was changed and consisted of fluconazole (100 mg/day) during conditioning until day + 7 and posaconazole (300 mg/day) thereafter until day + 100 or while on steroids.

URTD was considered in recipients with upper respiratory symptoms (rhinorrhea, sore through, sinusitis, otitis, or pharyngitis) and a positive identification of CARV by PCR test in respiratory samples and the lack of LRTD symptoms without any sign of pulmonary infiltrates in chest X-ray or CT scan. We classified LRTD as possible or confirmed according to previous definitions. 21 There were no probable episodes since we do not perform bronchoscopies in patients without radiological evidence of pulmonary involvement. We defined CARV URTD and/or LRTD episodes following ECIL-4 guidelines. 22 According to the ECIL-4 recommendations, an episode was considered to be resolved when complete remission of respiratory symptoms was observed. In cases with a new onset of respiratory symptoms in which we detected the same virus from the prior CARV episode along with another newly emerging CARV, we considered it as a new co-viral infectious disease episode. In contrast, cases in which we detected a CARV and the recipient had long-lasting respiratory symptoms that were re-screened during follow-up testing positive for a new emerging CARV along with the initial CARV were considered as a unique co-viral CARV infectious disease episode.

As per protocol, we started oseltamivir in allo-HSCT recipients with influenza infection provided the respiratory symptoms have not been resolved at the time of microbiological results. Annual influenza vaccination was also recommended to all patients at both transplant centers after the third month following allo-HSCT. For patients with moderate-to-severe GVHD at the time of vaccination program who had received gammaglobulin, antithymocytic globulin (ATG), or rituximab within the three months before the flu vaccine period, vaccine administration remained at physician discretion. 17 Respiratory syncytial virus (RSV) and human parainfluenza virus (HPIV) were managed according to our interventional protocol. 23 Briefly, oral ribavirin was given at a loading dose (maximum daily dose of 30 mg/kg) until resolution of respiratory symptoms in recipients with LRTD caused by RSV or HPIV, whereas patients with URTD must had 3 or more ISI points and/or 2 or more risk factor according to the ECIL guidelines, 22 and/or presenting one or more co-infective virus(es) before starting ribavirin. Routine prophylactic intravenous immunoglobulins (0.4 g/ kg) were given when IgG serum levels were below 300 mg/dL.

definitions of the European Organization for Research and Treatment of Cancer and Mycoses Study Group (EORTC/MSG). 24 Possible IFD episodes were considered, but finally, they were not included in the analyses. The IFD date was taken as the date the test yielded the diagnosis. IFD was considered to be directly related to CARV infection when it occurred in the 2 months following either the date of CARV detection or date of most recent CARV detection (in cases of longlasting active respiratory symptoms and viral shedding with several consecutive PCR tests detecting the same CARV). Recipients with probable-proven IFD prior to the development of a CARV episode were not considered as a CARV-related IFD, and they were not included in the analyses. Acute graft-versus-host disease (aGvHD) was defined according to standard criteria. 25 

CARV testing was performed with three RT-PCR multiplex platforms, two of which have been described in detail elsewhere. 17, 18 Briefly, the Luminex xTAG RVP Fast v1 assay (Luminex Molecular Diagnostics) and the CLART ® PneumoVir DNA array assay (Genomica) were used at the HCUV and at HLF, respectively. At HLF from July 2018 onwards, CARV screening in allo-HSCT recipients was performed by BioFire FilmArray ® Respiratory Panel week from day of stem cell infusion until hospital discharge and on a weekly basis thereafter until day + 100 and at each outpatient visit while receiving steroids to treat GvHD afterward. GM was also screened in bronchoalveolar lavage fluid.

The primary endpoint of the current study was to determine the IFD incidence and its RFs in allo-HSCT recipients with prior documented CARV, URTD, and/or LRTD. Secondary endpoints included the analysis of CARV-related IFD characteristics and its effect on overall survival (OS).

Categorical variable frequencies were compared using the χ 2 test (Fisher's exact test), whereas the Mann-Whitney U test was used to compare differences between medians. Generalized estimating equation (GEE) 26 was used to assess the association of clinical and biological RFs with CARV-related IFD. This method is used when analyzing clustered data, as ours, where episodes can be grouped within the same patient. GEE fits marginal mean models with asymptotically normal and consistent estimators if there is a correct specification of marginal means. Two different models were carried out in the current study: one to evaluate RFs for IFD after overall CARV (1) and those limited to the lower respiratory

where response variable is IFD (Y = 0, 1) and factors are as follows:

ATG as a part of conditioning (x 1 = 0, 1), CARV LRTD (x 2 = 0, 1), Allo- 

CMV status (x 5 = 0, 1). Moreover, bj is the random effect associated with each individual j and sij the experimental error, both are considered random and independent.

The method for best model selection was "quasi-likelihood under the independence model criterion" (QIC). This method was 

One hundred and forty-two (49%) out of 287 recipients had 1 CARV episode, 66 recipients (23%) had 2 CARV episodes, 38 (13%) had Three-hundred and ninety-four CARV episodes (66%) were limited to the URTD, whereas 203 (34%) had LRTD involvement (106 possible LRTD and 97 proven LRTD). Antiviral therapy with oseltamivir or ribavirin was given in 169 (28%) out of 597 CARV episodes. Table 2 summarizes the most common CARV types and rates of URTD and LRTD.

Out of 287 allo-HSCT recipients, 29 (10%) developed IFD within two months after a CARV episode at a median of 21 days (range 0-158 days) from the day of CARV diagnosis. In five out of 29 cases (17%), IFD was diagnosed at median of 109 days (range 66 to 158 days) after the initial CARV diagnosis. However, these cases had long-lasting respiratory symptoms and repeated PCR test detected the same CARV subtype in the two months before the diagnosis of IFD. All the IFDs involved the lungs, and in 26 (89%) cases, the diagnostic was IA, meeting criteria of probable (n = 24) or proven (n = 2). Probable IA cases had GM index in blood (n = 18) and/or BAL (n = 11) above the threshold values. 

GEE models of RFs for IFD after overall CARV episodes and those with LRTD are shown in Table 4 .

In order to identify transplant and CARV circumstances related to IFD, we included the 597 evaluable recipient/episode pairs. The Developing IFD after CARV was associated with worse OS at three months after CARV diagnosis. OS was 93% for CARV episodes not developing IFD vs 79% for those with IFD (P = .003). However, the OS in allo-HSCT recipients with LRTD developing IFD was similar to those without IFD (76% vs 83%, respectively, P = .3; Figure 2A ,B).

This study shows an overall IFD rate of 10% (29 out of 287 allo-HSCT recipients), whereas the rate was 5% according to overall CARV infectious episodes (29 out of 597 CARV episodes). GEE analysis identified ATG, CARV LRTD, having a CARV episode within the first year CARV Without IFD (n = 568)

Immunodeficiency Scoring Index, n (%) a ANC < 0.5 × 10 9 /L (3pts) 42 (7) 5 (17) .07

ALC< 0.2 × 10 9 /L (3pts) 72 (13) Recent or pre-engraftment allo-HSCT (1pt) 54 (10) 4 (14) .5

Low risk (0-2) 198 (35) 2 (7) Moderate risk (3-6) 308 (54) 21 (72) .005

High risk (7-12) 61 (11) 6 (21)

Other characteristics a .05

Day + 60 23 (5) 6 (21) .002

Day + 90 36 (6) 6 (21) .01

Abbreviations: ALC, absolute lymphocyte count; Allo-HSCT, allogeneic hematopoietic stem cell transplantation; ANC, absolute neutrophil count; ATG, antithymocyte globulin; CARV, communityacquired respiratory virus; GvHD, graft-versus-host disease; IFD, invasive pulmonary infectious fungal disease; IS, immunosuppressants; LRTD, lower respiratory tract disease. a All variables were captured at the time of CARV diagnosis.

TA B L E 3 Clinical and biological characteristics of CARV episodes in allo-HSCT recipients according to the development of a later invasive pulmonary infectious disease after transplant and corticosteroids during CARV as the main RFs for IFD. These RFs led to the stratification of 3 risk groups with statistically significant differences in IFD rates. Remarkably, patients at low risk (none of the RFs) had a very low IFD rate (0.5%). Although the IFD rate was still low (5%) in recipients with 1 or 2 RFs, the recipients with 3 or 4 RFs showed a higher rate of IFD (17%). Additionally, we found ATG, active GvHD, and a CARV episode during the first year of transplant as the main RFs for IFD in recipients with CARV LRTD.

Although the relationship between CARVs and invasive mold infections and/or IA has been consistently established in the allo-HSCT setting, 5, 7, 9, 33 the true rate of later-occurring IFD in recipients developing CARV infections after allo-HSCT is not known.

Data from retrospective series reported rates of IFD after CARV in allo-HSCT recipients as ranging from 18% to 41%. 5, 33 However, our IFD rates vary according to CARV location (URTD or LRTD), time of CARV diagnosis, and presence of concurrent RFs. In this sense, the IFD rate in recipients with URTD was 1%, whereas it was 12%

in those with LRTD. The IFD rate was even higher (17%) in recipients developing a CARV LRTD during the first year after stem cell infusion. Our data show that IFD rates were lower than previously CARV involvement in alterations to the bronchial mucosa or pulmonary defensive mechanisms. 34, 35 The fact that IFD was a later event in our series [23 (79%) of 29 recipients developed IFD after day + 100] might explain why neutropenia did not enter as a potential RF in the GEE model. In contrast, the use of ATG was an important RF for IFD. This finding is not surprising, since ATG produces lymphopenia and a significant deferral

in T-cell immune reconstitution for longer than a year after stem cell infusion. 36, 37 ATG has been previously identified as a RF for IA. 5 In fact, Aspergillus-specific CD4+ T-cell activity has been recognized as significant in regulating active pulmonary inflammation and likely adding antifungal effector activity. [38] [39] [40] Another potential explanation could be that ATG in our series was mainly used in the context of single CBU transplantation (78% of overall ATG use) and this procedure has been consistently associated with higher incidence of IFD than other sources of hematopoietic stem cells. 41 As per protocol, in the current series, the recipients on corticosteroids therapy received triazole antifungal prophylaxis.

However, corticosteroids use was still associated with increased risk of IFD during CARV infections in our series. This finding is not completely unexpected since it is well established that corticosteroids increased the risk of IFD in allo-HSCT recipients. Finally, the development of invasive pulmonary IFD complicating CARV infections after allo-HSCT had a negative effect on outcome.

The dismal prognosis of IFD after allo-HSCT is well characterized. 1 In the current series, three-month all-cause mortality was significantly higher in recipients with IFD. This fact highlights the need for effective diagnostic and prevention strategies for detecting and reducing IFD in these severely immunosuppressed patients.

We acknowledge that this study has some limitations, such as the use of different antifungal prophylaxis strategies over time and the use of three different PCR methods differing (minimally) in analytical performance. In spite of this, our study has strengths that merit consideration, notably our use of molecular testing and our data collection from a prospective CARV survey.

In conclusion, we provide evidence that IFD after CARV infection is significant, showing a negative association on outcomes. Allo-HSCT recipients with 3 or 4 RFs may require close monitoring for the future development of IFD.

We would like to thank Juan A. Carbonell-Asins from the 

Invasive aspergillosis following hematopoietic cell transplantation: outcomes and prognostic factors associated with mortality

Incidence and outcome of invasive fungal diseases after allogeneic hematopoietic stem cell transplantation: a Swiss transplant cohort study

Risks, diagnosis and outcomes of invasive fungal infections in haematopoietic stem cell transplant recipients

Risks and outcomes of invasive fungal infections in recipients of allogeneic hematopoietic stem cell transplants after nonmyeloablative conditioning

Epidemiology of invasive mold infections in allogeneic stem cell transplant recipients: biological risk factors for infection according to time after transplantation

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Invasive fungal infections after allogeneic peripheral blood stem cell transplantation: incidence and risk factors in 395 patients

Invasive aspergillosis in allogeneic stem cell transplant recipients: changes in epidemiology and risk factors

Invasive pulmonary aspergillosis associated with influenza B

Invasive pulmonary aspergillosis during influenza: a fortuitous association

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Influenza A and aspergillosis

Invasive pulmonary aspergillosis complicating influenza A pneumonia in a previously healthy patient

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Epidemiologic and clinical characteristics of coronavirus and bocavirus respiratory infections after allogeneic stem cell transplantation: a prospective single-center study

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Invasive fungal disease in patients undergoing umbilical cord blood transplantation after myeloablative conditioning regimen

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ECIL-4): guidelines for diagnosis and treatment of human respiratory syncytial virus, parainfluenza virus, metapneumovirus, rhinovirus, and coronavirus

A risk-adapted approach to treating respiratory syncytial virus and human parainfluenza virus in allogeneic stem cell transplantation recipients with oral ribavirin therapy: a pilot study

Revised Definitions of Invasive Fungal Disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group

Clinical manifestations of graft-versus-host disease in human recipients of marrow from HL-A-matched sibling donors

Longitudinal data analysis using generalized linear models

Akaike's information criterion in generalized estimating equations

R: A language and environment for statistical computing

The r package geepack for generalized estimating equations

Package 'mumin'. Version, 1:18

Statistical methods for the analysis and presentation of the results of bone marrow transplants. Part I: unadjusted analysis

Statistical methods for the analysis and presentation of the results of bone marrow transplants. Part 2: Regression modeling

Lower respiratory tract respiratory virus infections increase the risk of invasive aspergillosis after a reduced-intensity allogeneic hematopoietic SCT

Immunity and pathophysiology of respiratory tract infections

The challenge of respiratory virus infections in hematopoietic cell transplant recipients

Analysis of engraftment, graft-versus-host disease, and immune recovery following unrelated donor cord blood transplantation

Graft-versus-host disease following allogeneic transplantation from HLA-identical sibling with antithymocyte globulin-based reduced-intensity preparative regimen

Distinct CD4+ T cell responses to live and heat-inactivated Aspergillus fumigatus conidia

Immune responses to Aspergillus fumigatus infections

Generation of highly purified and functionally active human TH1 cells against Aspergillus fumigatus

Invasive aspergillosis before allogeneic hematopoietic stem cell transplantation: 10-year experience at a single transplant center