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Definitions of Infectious Diseases and Complications After Stem Cell Transplant

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Definitions of Infectious Diseases and Complications After Stem Cell Transplant 1 IDWP Definitions of Infectious Diseases and Complications after Stem Cell Transplant A proposal from the Infectious Diseases Working Party of the EBMT November 1st, 2001. Version n° 1. Catherine Cordonnier, Dan Engelhard, Per Ljungman, Adrian Dekker, J. P. Donnelly, Hermann Einsele, Ernst Holler, Hartmut Link, Anna Locasciulli, Rodrigo Martino, Fritz Offner, Pierre Reusser, Montserrat Rovira, Andrew Ullman, Kate Ward on behalf of the Infectious Diseases Working Party of the EBMT In the past, some confusion and variability in reporting has been noted with significant differences 2 in incidences of infection among centres which may not be accurate. The growing knowledge of infectious complications after stem cell transplant makes it important that investigators agree on common definitions in the reporting of data, to insure that series are comparable. This proposal aims to provide standard definitions for infectious complications occurring after stem cell transplantation within the EBMT. This should be useful for two purposes: - to make the data given to the EBMT Registry, more precise and common to all the centres. This should improve data management, insure the quality of the data in the EBMT centres and facilitate prospective and retrospective studies through the registry. Although these definitions are not fully exhaustive and will probably evolve in the future, the Infectious Diseases Working Party and the Registry Committee recommend the EBMT members use the present version of these definitions when filling the infection-related complication section in the MED B forms. - to provide official definitions for the Group, so that authors may refer to these definitions for studies or surveys, including those done outside the registry. It is not the purpose of this text to force the EBMT members to use these definitions, but only to facilitate their work, so that they may choose, when publishing on a topic, between refering to the EBMT definitions, or to others. These definitions are drawn either from published guidelines whenever possible, or from the consensus emerging from the members of the Infectious Diseases Working Party when no satisfactory definition has previously been proposed in the literature. These definitions are presented in two parts: - the first part summarizes the different clinical entities which are usually observed. Most of these entities - but not all - are intended for entering infectious complications in the EBMT data base. - the second part covers definitions regarding specific pathogens: bacteria, fungi, viruses, others. Most of the items concern clinical entities defined in the first part, and aim to help the investigator to establish the relationship between the clinical presentation, and the role of a pathogen. We have restricted the definitions to the most difficult items and do not mention obvious definitions of widely accepted infections or diseases. Because of the introduction of more and more sensitive tests to detect pathogens, the definitions should be as clear as possible concerning the diagnostic value of each new test in a given clinical setting. It is clear that definitions for infectious diseases or syndromes may evolve with the progress of investigative procedures, or understanding of the disease. Therefore, once a consensus is obtained, these definitions should be reviewed every two years, or more often where necessary. The EBMT members are encouraged to make suggestions on this version to the chairperson of the IDWP. 1 - CLINICAL ENTITIES 3 1. 1. FEBRILE NEUTROPENIA 1. 1. 1. Fever of unknown origin or unexplained fever 1. 1. 2. Clinically defined infection 1. 1. 3. Microbiologically defined infection 1.2. BACTEREMIA, FONGEMIA,VIREMIA 1.2.1. Bacteraemia 1.2.2. Fungaemia 1.2.3. Viraemia 1. 3. SEPSIS and SEPTIC SHOCK 1. 4. SEVERE SEPSIS and MULTIORGAN FAILURE 1. 5. ACUTE RESPIRATORY DISTRESS SYNDROM (ARDS) 1.6. PNEUMONIA 1.6.1Pneumonia 1.6.2. Idiopathic pneumonia syndrome 1. 7. HEPATITIS 1. 8. CENTRAL NERVOUS SYSTEM INFECTION 1.9. GUT INFECTION 1.9.1.Typhlitis/Neutropenic Enterocolitis 1.9.2. Clostridium difficile associated diarrhoea or pseudomembranous colitis 1. 10. SKIN INFECTION 1. 11. CYSTITIS 1. 12. RETINITIS 1. 13. CATHETER RELATED INFECTION 1. 13. 1 Catheter related bloodstream infection 1. 13. 2. Infusate-related bloodstream infection 1. 13. 3. Catheter colonization 1. 13. 4. Exit-site infection 1. 13. 5. Tunnel infection 1. 13. 6. Septic thrombophlebitis 1. 13. 7. Insertion site infection 1. 13. 8. Pocket (Port-A-Cath) infection 2. SPECIFIC DEFINITIONS RELATED TO PATHOGENS 2. 1. BACTERIAL INFECTIONS 2. 1. 1. Bacteraemia 2. 1. 2. Bacterial pneumonia 2. 1. 3. Mycobacterial infections 2. 1. 4. Legionellosis 2. 2. FUNGAL INFECTIONS 2. 2. 1. Common fungal infections 2. 2. 2 . Pneumocystis carinii pneumonia 2. 3. VIRAL INFECTIONS 2. 3. 1. HSV 2. 3. 2. VZV 2. 3. 3. CMV 4 2. 3. 4. EBV 2. 3. 5. HHV-6 2. 3. 6. HHV-7 2. 3. 7. HHV-8 2. 3. 8. Respiratory viruses 2. 3. 9. Adenovirus 2. 3. 10. HBV 2. 3. 11. HCV 2. 3. 12. HIV 2. 3. 13. Papovavirus 2. 3. 14. Parvovirus B19 2.4. OTHERS 2.4.1. P. carinii (section 2.2.2) 2.4.2. Toxoplasmosis 2.4.2.1 Toxoplasma disease 2.4.2.2 Toxoplasma infection 1 - CLINICAL ENTITIES 5 1. 1. FEBRILE NEUTROPENIA Febrile neutropenia is defined by the onset of fever (a single oral temperature 38.3 °C or. 38.0°C twice within 12 hours, in the absence of known causes), local inflammation, or any infectious symptom in a patient with polymorphonuclear count <500/mm3, or expected at this level in the next 48 hours, due to a recent chemotherapy. According to the presence of local inflammation evocative for infection, and to the microbial documentation, the episodes of febrile neutropenia are separated in three categories: 1. 1. 1. Fever of unknown origin or unexplained fever Isolated fever, no local inflammation evocative for clinical infection, and no microbial documentation of the episode. 1. 1. 2. Clinically defined infection (Clinically documented infection) Fever associated with a local inflammation such as pneumonia, skin-infection, or cellulitis, whose microbiological pathogenesis cannot be proven or which cannot be examined. 1. 1. 3. Microbiologically defined infection (Microbiologically documented infection), with or without bacteremia Infectious organisms detected in blood cultures, even without localized inflammation (no clinical focus), OR localized, microbiologically documented, infection, with, or without positive blood cultures. Infectious Disease Society of America: http://www.idsociety.org. Guidelines for the use of antimicrobial agents in neutropenic patients with unexplained fever. Hughes WT, et al. Clin Infect Dis 1997;25:551–73 1. 2. BACTERAEMIA, FUNGAEMIA,VIRAEMIA 1.2. 1. Bacteraemia is defined by the presence of viable bacteria in the blood. For more details, please see section 2.1.1: Bacterial infections. 1.2. 2. Fungaemia Yeasts: Fungemia is defined by at least one positive blood culture of Candida and other yeasts in patients with temporally related clinical signs and symptoms compatible with the relevant organism. Moulds: Fungemia is defined by positive blood culture of fungi excluding Aspergillus spp. And Penicillium spp. Other than P. marneffei, accompanied by temporally related clinical signs and symptoms compatible with the relevant organism. See also section 2.2.: Fungal infections. 1. 2. 3. Viraemia is defined by the presence of virus demonstrated by culture, antigenemia, or nucleic acid detection in a blood sample. However, due to the high sensitivity of the techniques, and to the possible presence of viruses in the blood without clinical consequences, the significance of viraemia should be carefully considered according to the type of virus. See section 2.3.: Viral Infections 6 1. 3. SEPSIS AND SEPTIC SHOCK Although not specifically mentionned in the original text, the following definitions have been designed for non-neutropenic patients. Most neutropenic patients with clinically documented or microbiologically documented infections have criteria for Sepsis according to the definition below. Consequently, we recommend that - for uncomplicated episodes of Febrile neutropenia, the patients be classified according to the definitions of Febrile neutropenia (Section 1.1) - for episodes of septic shock or multivisceral failure in neutropenic patients, the patients be classified both according to the definitions of Febrile neutropenia AND to the definitions of septic shock and multivisceral failure (Sections 1.3 and 1.4.) Sepsis is the association of a clinically or microbiologically documented infection AND of 2 or more of the SIRS (Systemic inflammatory response syndrome) conditions which are: - temperature > 38°C or < 36°C - heart rate > 90/minute - respiratory rate > 20 /minute or Pa CO2 < 32mmHg - white blood cell count > 12,000 or < 4,000/mm3 or > 10% immature (bands) forms. Septic shock is defined by the presence of sepsis and hypotension (systolic blood pressure <90 or reduction of > 40 mmHg from baseline) despite adequate fluid resuscitation, along with the presence of perfusion abnormalities. Patients who are on inotropic or vasopressor agents may not be hypotensive at the time that perfusion abnormalities are measured. Muckart DJJ, Bhagwanjee S. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definition of the systemic inflammatory response syndrome (SIRS) and allied disorders in relation to critically injured patients. Crit Care Med 1997; 25: 1789-1795. 1. 4. SEVERE SEPSIS AND MULTI-ORGAN FAILURE OF INFECTIOUS ORIGIN Sepsis is defined severe when associated with at least one of the following signs of acute organ dysfunction, not explained by any cause except severe infection: (1) metabolic acidosis (arterial blood pH <7.36 or increased blood lactacte level); (2) arterial hypoxaemia (PaO2 <75 mmHg or PaO2 / FiO2 <250); (3) acute oliguria (< 0.030L/h for 3h, or 0.7 L/24h); (4) coagulopathy (50% decrease in Quick time or platelet count or a decrease in platelet count to <100 10 9/L); (5) acute alteration in mental status (Glasgow score < 14); (6) hypotension (a systolic blood pressure <90mmHg or a decrease in systolic blood pressure of at least 40 mmHg from baseline).
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