Christine Robin

Cytomegalovirus (CMV) infection and disease (CMV episodes) are global concerns after allogeneic hematopoietic stem cell transplantation (HSCT). They affect survival, both by direct and indirect effects. Due to safety issues of current anti-CMV antivirals, long-term CMV prophylaxis is poorly tolerated and the most common strategy to decrease the incidence of CMV disease is preemptive. New, less toxic, molecules are currently being assessed for CMV prophylaxis which should replace or considerably decrease the preemptive approach. The aim of this study was to assess the economic burden of CMV episodes after HSCT with a preemptive approach. We analyzed data from 208 consecutive adults transplanted in our institution, between 2008 and 2013. Hospital resource utilization was retrieved via the linked hospital admissions and Diagnostic Related Groups for the period of conditioning to 12 months after transplant. CMV episodes occurred in 70 patients (34%) over the first 12 months following HSCT, after a mean of 75 days (median: 46 (7–334)). The mean total length of stay was significantly associated with the occurrence of a CMV episode (113.9 vs. 87.5 days, p = 0.0002) but was associated neither with the pre-transplant CMV serology of donors/recipients nor with survival. The mean cost of transplant was €104,016 (SD = €37,281) after 12 months. Bivariate and multivariate analyses indicated that the occurrence of >1 CMV episode increased the costs of allogeneic HSCT by 25–30% (p < 0.0001). Our study, which is the largest, single-institution cost study of allogeneic HSCT in Europe, shows that two or more CMV episodes significantly increased the transplant cost. New prophylactic strategies to prevent CMV infection and disease should decrease transplant costs.

This study focuses on the epidemiology and management of mucormycosis in hematopoietic stem cell transplant patients, a life-threatening mold infection whose incidence has increased over the past decades.Mucormycosis may occur in hematopoietic stem cell transplant recipients with severe graft-versus-host disease, steroids, neutropenia, iron overload, diabetes, and malnutrition, or those who received antifungals not active against Mucorales. Its incidence in allogeneic hematopoietic stem cell transplant is around 0.3%. As Mucorales are not susceptible to voriconazole and candins, and as mucormycosis often mimics aspergillosis, it is extremely important to have a precise diagnostic to correctly manage the patient. The reversed halo sign on chest computed tomography has been associated to mucormycosis in neutropenic patients, but is not pathognomonic. Direct fungal identification is crucial. Molecular approaches are developed that may be extremely useful for early diagnosis.Although randomized trials are quite impossible to run, due to the rarity of the disease, the recent numerous data have allowed the elaboration of European guidelines for the management of mucormycosis. Lipid formulations of amphotericin B, and especially liposomal amphotericin B at high doses (5-10 mg/kg/day), are the standard treatment, combined with surgery and control of favoring factors. The prognosis is poor, and any delay in the initiation of therapy may impact on outcome.