| Objective:Carbapenem-resistant Enterobacteriaceae(CRE)bacteria,which are resistant to carbapenem antibiotics,have been widely spread and become the main source of infection leading to death in patients undergoing allogeneic hematopoietic stem cell transplantation(allo-HSCT)worldwide.The aim of this study is to explore the risk factors for CRE colonization in the intestines of patients undergoing allo-HSCT,establish a risk model for CRE colonization,and further analyze the impact of CRE colonization on post-transplant clinical outcomes and complications.Methods:Clinical data of 343 patients with hematologic diseases who underwent allo-HSCT at the First Affiliated Hospital of Soochow University from June 1,2021 to June 1,2022 were collected.All patients underwent rectal swab screening before admission and were divided into CRE colonization group and non-CRE colonization group based on laboratory results.Chi-square test was used to analyze the differences in clinical characteristics between the colonization and non-colonization groups.Logistic regression was used to screen for risk factors for CRE colonization and construct a risk prediction model.Cox regression was then used to compare and analyze the differences between the colonization and non-colonization groups in terms of hematopoietic reconstruction,bloodstream infection(BSI),graft versus host disease(GVHD),Epstein Barr virus(EBV)infection,cytomegalovirus(CMV)infection,transplantation associated thrombotic microangiopathy(TA-TMA),relapse,Progression-free survival(PFS),non-relapse mortality(NRM),and survival prognosis.Furthermore,Cox multivariate analysis was performed to explore the impact of CRE colonization on transplant-related outcomes.Results:1.Among 343 patients with hematological malignancies,there were 135 cases in the carbapenem-resistant Enterobacteriaceae(CRE)colonization group and 208 cases in the non-CRE colonization group,with a colonization rate of 39.3%(135/343).Klebsiella pneumoniae accounted for 41%,Escherichia coli accounted for 26%,and Enterobacter cloacae accounted for 17%of the colonization.Chi-square test was performed to analyze the differences in sex(P=0.00),disease remission status before transplantation(P=0.01),pulmonary infection within 30 days before colonization(P=0.00),gastrointestinal infection within 30 days before colonization(P=0.00),perianal infection within 30 days before colonization(P=0.00),exposure to carbapenem antibiotics within 30 days before colonization(P=0.00),and infusion of mononuclear cell count(P=0.04)before colonization.Multivariate logistic regression analysis showed that gender(OR 2.94,95%CI 1.76-4.90,P=0.00),pulmonary infection within 30 days before colonization(OR 2.38,95%CI 1.42-3.90,P=0.00),gastrointestinal infection within 30 days before colonization(OR 1.82,95%CI 1.08-3.05,P=0.02),perianal infection within 30 days before colonization(OR 2.58,95%CI 1.11-5.99,P=0.03),and exposure to carbapenem antibiotics within 30 days before colonization(OR 3.72,95%CI 2.22-6.23,P=0.00)were independent risk factors for CRE colonization.A risk prediction model was established based on predictive factors such as gender,pulmonary infection within 30 days before colonization,gastrointestinal infection within 30 days before colonization,perianal infection within 30 days before colonization,and exposure to carbapenem antibiotics within 30 days before colonization,and was validated.The maximum area under the receiver operating characteristic curve of the model was 0.767,indicating good accuracy.2.In terms of hematopoietic reconstruction,the engraftment rates of neutrophil and platelets were 97.0%and 87.4%,respectively,in the CRE intestinal colonization group,while the engraftment rates were 99.5%and 94.2%,respectively,in the noncolonization group.After transplantation,the CRE intestinal colonization group had a blood stream infection rate of 28.9%,a recurrence rate of 11.9%,a non-recurrence mortality rate of 8.9%within 100 days,and a survival rate of 90.4%winthin 100 days and an overall survival rate of 80.7%.In contrast,the non-colonization group had a blood stream infection rate of 4.3%,a recurrence rate of 5.8%,a non-recurrence mortality rate of 1.4%within 100 days,and a survival rate of 97.6%within 100 days and an overall survival rate of 92.3%.The CRE intestinal colonization group had a significant decrease in platelet implantation rate(P<0.001)and significantly lower 100-day survival(P=0.0034)and overall survival(P=0.003)compared to the negative colonization group.Furthermore,the CRE intestinal colonization group had a significantly higher incidence of post-transplant blood stream infection(P<0.001),recurrence rate(P=0.014),non-recurrence death rate at 100 days(P<0.001),and overall non-recurrence death rate(P=0.0021)compared to the negative colonization group.Multivariate analysis revealed that CRE intestinal colonization(HR 0.66,95%CI 0.52-0.83,P=0.00),incomplete remission before transplantation(HR 0.48,95%CI 0.32-0.72,P=0.00),and HLA mismatch(HR 0.64,95%CI 0.50-0.82,P=0.00)were independent risk factors for decreased platelet implantation.CRE intestinal colonization(HR 5.71,95%CI 2.66-12.30,P=0.00)and perianal infection within 30 days before colonization(HR 2.23,95%CI 1.12-4.44,P=0.02)were independent risk factors for post-transplant blood stream infection.Incomplete remission before transplantation(HR 7.44,95%CI 3.36-16.49,P=0.00)was an independent risk factor for recurrence.CRE intestinal colonization(HR 5.5,95%CI 1.53-19.73,P=0.01)and incomplete remission before colonization(HR 3.35,95%CI 1.13-9.90,P=0.03)were independent risk factors for non-relapse mortality within 100 days post-transplant.CRE intestinal colonization(HR 2.68,95%CI 1.31-5.48,P=0.00)and incomplete remission before transplantation(HR 2.71,95%CI 1.15-6.35,P=0.02)were independent risk factors for non-relapse mortality.CRE intestinal colonization(HR 3.28,95%CI 1.14-9.44,P=0.03)and incomplete remission before transplantation(HR 4.09,95%CI 1.43-11.73,P=0.01)were independent risk factors for 100-day survival.CRE intestinal colonization(HR 1.89,95%CI 1.02-3.49,P=0.04),incomplete remission before transplantation(HR 4.21,95%CI 2.05-8.62,P=0.00),and relapse(HR 2.21,95%CI 1.05-4.62,P=0.04)were independent risk factors for overall survival.Conclusion:1.The incidence of carbapenem-resistant Enterobacteriaceae(CRE)colonization is high in allogeneic hematopoietic stem cell transplant(allo-HSCT)patients,and gender,pulmonary infection,gastrointestinal infection,perianal infection,and exposure to carbapenem antibiotics within 30 days before colonization may be independent risk factors for CRE colonization.2.CRE colonization may lead to delayed platelet engraftment,increased posttransplant bloodstream infections,increased non-relapse mortality,shortened posttransplant 100-day survival and overall survival,and CRE colonization was an independent risk factor for platelet engraftment,post-transplant bloodstream infections,post-transplant 100-day non-relapse mortality,100-day survival,non-relapse mortality and overall survival. |
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