Winston G. Ho

A Controlled Trial of Fluconazole to Prevent Fungal Infections in Patients Undergoing Bone Marrow Transplantation

BACKGROUND AND METHODS Superficial and systemic fungal infections are a major problem among severely immunocompromised patients who undergo bone marrow transplantation. We performed a double-blind, randomized, multicenter trial in which patients receiving bone marrow transplants were randomly assigned to receive placebo or fluconazole (400 mg daily). Fluconazole or placebo was administered prophylactically from the start of the conditioning regimen until the neutrophil count returned to 1000 per microliter, toxicity was suspected, or a systemic fungal infection was suspected or proved. RESULTS By the end of the treatment period, 67.2 percent of the 177 patients assigned to placebo had a positive fungal culture of specimens from any site, as compared with 29.6 percent of the 179 patients assigned to fluconazole. Among these, superficial infections were diagnosed in 33.3 percent of the patients receiving placebo and in 8.4 percent of the patients receiving fluconazole (P less than 0.001). Systemic fungal infections occurred in 28 patients who received placebo as compared with 5 who received fluconazole (15.8 percent vs. 2.8 percent, P less than 0.001). Fluconazole prevented infection with all strains of candida except Candida krusei. Fluconazole was well tolerated, although patients who received it had a higher mean increase in alanine aminotransferase levels than patients who received placebo. Although there was no significant difference in overall mortality between the groups, fewer deaths were ascribed to acute systemic fungal infections in the group receiving fluconazole than in the group receiving placebo (1 of 179 vs. 10 of 177, P less than 0.001). CONCLUSIONS Prophylactic administration of fluconazole to recipients of bone marrow transplants reduces the incidence of both systemic and superficial fungal infections.

Ganciclovir Prophylaxis of Cytomegalovirus Infection and Disease in Allogeneic Bone Marrow Transplant Recipients: Results of a Placebo-Controlled, Double-Blind Trial

Cytomegalovirus (CMV) infection is a frequent cause of morbidity and mortality after allogeneic bone marrow transplantation [1, 2]. Approximately 50% of all allogeneic transplant recipients develop CMV infection, which is more common in CMV-seropositive patients [1]. Some patients with CMV infection are asymptomatic, but many develop pneumonia, gastroenteritis, fever and wasting, or hepatitis. In a recent review of CMV infection at several transplant centers, the average incidence of CMV pneumonia in allogeneic transplants was 15%, and the mortality was 80% to 90% [1]. Treatment of CMV pneumonia with antiviral agents or intravenous immunoglobulin has generally been ineffective [1], although the combination of ganciclovir and immunoglobulin has been reported to increase survival to 50% to 60% at some centers [3-5]. Attempts to prevent CMV infection and disease in bone marrow transplant recipients have produced mixed results. In CMV-seronegative patients, most CMV infections can be prevented by the use of CMV-seronegative blood products [6]. Prophylactic intravenous immunoglobulin also modifies the severity of CMV infection in CMV-seronegative patients and decreases the risk for acute graft-versus-host disease (GVHD) and interstitial pneumonia [7, 8]. On the other hand, effective prophylaxis for CMV reactivation and pneumonia in patients who are CMV-seropositive at the time of transplantation has not been clearly established. Previous trials of prophylactic vidarabine, human leukocyte interferon, and low-dose acyclovir showed no clinically significant effect [1]. In a nonrandomized, controlled trial, high doses of prophylactic acyclovir were associated with a decreased incidence of CMV infection and CMV disease [9]. However, the incidence of CMV infection and CMV-related pneumonia was 59% and 19%, respectively, despite the high doses of acyclovir. The efficacy of CMV immune plasma or immunoglobulin in CMV-seropositive patients is also uncertain [7, 10, 11]. Ganciclovir, an acyclic nucleoside analog of guanosine, has recently become available for treatment of CMV infection in immunocompromised patients [12]. In vitro, ganciclovir is approximately 50 times more active than acyclovir against CMV isolates [13]. Thus, we initiated a placebo-controlled, double-blind, randomized trial of prophylactic ganciclovir in CMV-seropositive allogeneic bone marrow transplants. Methods From May 1987 to August 1990, patients hospitalized at the UCLA Center for the Health Sciences were enrolled in the study if they met the following criteria: undergoing allogeneic bone marrow transplantation for hematologic malignancy or aplastic anemia; 12 years of age or older; seropositive for CMV antibody; and no evidence of pneumonia or other CMV clinical syndrome. Informed consent approved by the UCLA Human Subject Protection Committee was obtained from each patient. Patients undergoing a second bone marrow transplant were excluded. Only three patients meeting the eligibility criteria and subsequently approached for consent refused to participate in the study. Transplant Procedure Details on conditioning therapy before transplantation and clinical management after transplantation have been reported previously [14-16]. Patients were given high-dose chemotherapy alone or with radiation therapy followed by intravenous infusion of bone marrow from a related or unrelated donor. Cyclosporine alone or in combination with methotrexate, corticosteroids, T-cell depletion, or immunotoxin (Xomazyme-CD5; Xoma Corporation, Berkeley, California) was used to prevent GVHD. Patients who developed GVHD were evaluated by standard criteria and treated with either corticosteroids alone or corticosteroids plus immunotoxin [14-16]. Trimethoprim-sulfamethoxazole was administered to all patients between the seventh and second days before transplantation and then for 2 consecutive days of each week between day 40 and day 150 after transplantation to prevent Pneumocystis carinii pneumonia [1]. Neither prophylactic acyclovir nor intravenous immunoglobulin was used. All patients received unscreened blood products that were not tested for CMV antibody. Study Drugs Patients were randomly assigned in a double-blind fashion to receive ganciclovir or placebo through a central intravenous catheter. The ganciclovir was given at a dosage of 2.5 mg per kg body weight every 8 hours intravenously, starting on the day that pretransplant conditioning therapy was initiated (usually day 7 before transplant) and continuing until the day before the bone marrow infusion. After transplantation, when the neutrophil count reached 1.0 109/L, the ganciclovir was resumed at a dosage of 6 mg/kg once per day, Monday through Friday, and continued until day 120 after transplant. The dosage was adjusted in patients with renal failure. For patients whose neutrophil count fell below 1.0 109/L while receiving the study drug, prophylaxis was temporarily discontinued. When the neutrophil count returned to a level greater than 1.0 109/L, the ganciclovir was restarted at a dosage of 6 mg/kg once per day on Monday, Wednesday, and Friday. If a patient developed documented interstitial pneumonia, gastrointestinal disease, or other clinical syndromes related to CMV, the primary physician could remove the patient from the study and treat the patient with ganciclovir. Laboratory Procedures The cytomegalovirus serologic status of patients and bone marrow donors was determined by latex agglutination (CMV SCAN; Becton Dickinson, Cockeysville, Maryland). After transplantation, serologic studies for CMV antibody were done every 2 to 4 weeks on all patients by both complement-fixation and enzyme-linked immunosorbent assay (ELISA) (CMV ELISA-IgG; Pharmacia Diagnostics, Fairfield, New Jersey). Viral cultures of throat, urine, and buffy coat were obtained from marrow transplant recipients before entry into the study and then once a week. Whenever appropriate, viral cultures of suspicious lesions, bronchoalveolar lavage, biopsy material, and autopsy tissue were performed. Tissue cultures were initially screened for viral antigen by immunofluorescence using monoclonal antibodies to viral proteins and then observed for 4 weeks to detect characteristic cytopathic effects. Bronchoalveolar lavage and biopsy material were also examined histologically for typical viral inclusions and immunohistochemically by indirect immunofluorescence using murine monoclonal antibodies to early and late CMV proteins. Complete blood counts and tests for serum creatinine, electrolytes, and liver function were done before, during, and after the study period to assess patients for treatment-related side effects. Diagnosis of Cytomegalovirus Infection and Disease Cytomegalovirus infection was diagnosed by isolation of CMV from a culture obtained from any site, a fourfold or greater increase in the CMV antibody titer on complement fixation, an increase in the CMV ELISA measurement to 1.1 units or greater, or the presence of typical CMV inclusion bodies in a tissue specimen. Interstitial pneumonia was diagnosed by tachypnea, hypoxemia, fever, and interstitial pulmonary infiltrates on a chest roentgenogram not explainable by other obvious causes. Cultures, histologic examination, and immunochemical staining of bronchoalveolar lavage or lung biopsy were done to determine the cause of interstitial pneumonia. Similarly, cultures, histologic examination, and immunochemical staining of an endoscopic biopsy of the gastrointestinal tract or a biopsy of the liver in a patient with associated symptoms and signs were used to diagnose CMV disease of the gastrointestinal tract and liver. The wasting syndrome related to CMV was defined as fever, anorexia, and weight loss not explainable by other causes in a patient with culture or serologic evidence of CMV infection. Statistical Analysis The Fisher exact test was used to compare differences in proportions. The Student t-test was used to compare means. Univariate comparisons of times to specific events were performed by the method of Kaplan and Meier and analyzed by the log-rank test. Confidence intervals (CIs) for 95% of differences are given where appropriate. Results Patient Characteristics One hundred thirty patients were enrolled in the study. However, 45 patients (20 placebo patients, 25 ganciclovir patients) were considered nonevaluable and were excluded from the efficacy analysis. Reasons for nonevaluability were as follows: early death within 9 to 34 days after the transplant (24 patients), marrow graft failure preventing administration of the study drug after transplant (9 patients), withdrawal of patient from the study (10 patients), and inadvertent enrollment of a patient undergoing a second transplant (2 patients). Fifteen placebo patients and 18 ganciclovir patients were not evaluable due to either early death or graft failure. Eight of the 45 patients removed from the study subsequently developed CMV infection (asymptomatic CMV excretion in five patients, fever and wasting in one patient, and pneumonia in two patients). The one patient with a CMV wasting syndrome and one of the two patients with pneumonia were initially randomized to receive ganciclovir. The other patient with CMV pneumonia was randomized to receive placebo. None of these patients received study drug after the transplant, and none was taking study drug when CMV disease developed. All determinations of evaluability were done blindly without knowledge of the patients treatment assignment and before the study code was broken. The characteristics of the 85 evaluable patients are summarized in Table 1. Forty-five patients received placebo, and 40 patients were given ganciclovir. The two groups of patients were similar in terms of age, sex, underlying disease, marrow source, GVHD prophylaxis, and the marrow donors CMV serologic status. More patients in the ganciclovir group received HLA-mismatched marrow (95% CI, 29% to 2%; P = 0.04) and

Antithymocyte Globulin Treatment in Patients with Aplastic Anemia: A Prospective Randomized Trial

We evaluated the efficacy of antithymocyte globulin for the treatment of moderate to severe aplastic anemia in a randomized controlled study. Eleven of 21 patients initially randomized to receive antithymocyte globulin (given intravenously on eight consecutive days) had sustained improvement in hematopoiesis within three months of treatment; none of 21 control patients who received supportive care alone improved (P = 0.0005). Six of 12 control patients who subsequently received antithymocyte globulin improved. Responders had gradual improvement in hematopoiesis, but none recovered completely normal peripheral-blood counts. The severity of bone-marrow failure, age, cause of aplastic anemia, and transfusion history had no apparent bearing on treatment outcome. The interval from diagnosis to antithymocyte globulin treatment correlated inversely with the chance of a treatment response, although this correlation was not statistically significant. These data indicate that antithymocyte globulin is effective in improving hematopoiesis in some patients with aplastic anemia.

Intravenous immune globulin for prevention of cytomegalovirus infection and interstitial pneumonia after bone marrow transplantation.

The effects of high doses of polyvalent intravenous immune globulin given for prophylaxis of cytomegalovirus infection and interstitial pneumonia in recipients of allogeneic marrow transplants were evaluated in a randomized controlled trial. Both symptomatic cytomegalovirus infection (21% compared with 46%, p = 0.03) and interstitial pneumonia (18% compared with 46%, p = 0.02) occurred less frequently in the recipients of intravenous immune globulin than in control patients. Prophylactic intravenous immune globulin was also associated with a lower incidence of graft-versus-host disease (34% in recipients compared with 65% in controls, p = 0.01), but its reduction in rates of interstitial pneumonia was independent of graft-versus-host disease and occurred in both patients with and without graft-versus-host disease. The high doses of immune globulin were well tolerated. Prophylactic intravenous immune globulin can modify the severity of cytomegalovirus infection and prevent interstitial pneumonia and possibly graft-versus-host disease in patients having allogeneic marrow transplantation.

Treatment of Donor Bone Marrow with Monoclonal Anti-T-Cell Antibody and Complement for the Prevention of Graft-Versus-Host Disease: A Prospective, Randomized, Double-Blind Trial

The effects of ex-vivo depletion of T lymphocytes from donor bone marrow using a monoclonal anti-T-cell antibody (CT-2) and complement on the outcome of allogeneic bone marrow transplantation was evaluated in a prospective, randomized, double-blind study of 40 patients with leukemia. Patients receiving T-cell-depleted bone marrow had a lower incidence of acute graft-versus-host disease than control patients (3 of 20 compared with 13 of 20; p = 0.004), and mortality due to acute graft-versus-host disease was reduced. Five patients in the T-cell-depletion group developed graft failure; all control patients had sustained engraftment (p less than 0.05). Clinically apparent relapse of leukemia occurred in 7 patients from the T-cell-depletion group and in 2 controls (p, not significant). Cytogenetic evidence of residual leukemia was also detected in the 5 patients with graft failure without overt relapse. Infections and overall survival were similar in the two groups. The effects of T-cell depletion on engraftment and recurrence of leukemia require further evaluation.

Cytomegalovirus Immune Plasma in Bone Marrow Transplant Recipients

The effects of passive immunization on cytomegalovirus infection and interstitial pneumonia in marrow transplants were evaluated in a randomized, controlled trial. Twenty-four patients received cytomegalovirus immune plasma before and after transplantation, and 24 patients were controls. Although the incidence of cytomegalovirus infection was similar in the control and plasma groups, symptomatic infection (12 of 24 versus five of 24, p = 0.07) and interstitial pneumonia (11 of 24 versus five of 24, p = 0.12) occurred less frequently in the group receiving plasma. Cytomegalovirus infection occurred in 11 of 13 recipients of leukocyte transfusions and in 16 of 35 patients not given leukocyte transfusions (p = 0.02). Among patients not given leukocyte transfusions, the incidence of cytomegalovirus infection was similar in the control and plasma groups, but symptomatic infection (eight of 18 versus one of 17, p = 0.03) and interstitial pneumonia (nine of 18 versus one of 17, p = 0.01) were significantly less in the group receiving plasma. These results suggest that passive immunization modifies cytomegalovirus infection in humans and prevents interstitial pneumonia in marrow transplants especially when leukocyte transfusions are not used.

Cytomegalovirus Infections Associated with Leukocyte Transfusions

Patients randomized to receive or not to receive prophylactic leukocyte transfusions were evaluated prospectively for serologic, histologic, and cultural evidence of cytomegalovirus infection. Recipients of prophylactic leukocyte transfusions and control subjects were similar with regard to age, sex, underlying disease, immunosuppressive therapy, and number of other transfusions. The recipients of prophylactic leukocyte transfusions (mean, 23.1) had significantly more cytomegalovirus infections (19 of 31 versus seven of 27, p = 0.01) than did control patients receiving no leukocytes or only therapeutic leukocyte transfusions (mean, 3.8). Twenty-seven of 66 donors of leukocytes were seropositive for cytomegalovirus complement-fixation antibody, but cytomegalovirus was not isolated from any of 62 leukocyte transfusions cultured for virus. These results are consistent with the hypothesis that latent cytomegalovirus may be present in leukocytes of blood donors with previous cytomegalovirus infection and after transfusion may be activated to produce active cytomegalovirus infection.

Selective Depletion Of Cd8+ Cells For Prevention Of Graft-versus-host Disease After Bone Marrow Transplantation A Randomized Controlled Trial

We performed a prospective randomized, double-blind study to assess the efficacy of selective depletion of CD8+ bone marrow cells in preventing acute graft-versus-host disease (GVHD) in 38 patients undergoing HLA-identical sibling donor bone marrow transplantation for leukemia. All patients received CsA for GVHD prophylaxis. Nineteen patients received marrow depleted of CD8+ cells by ex vivo treatment with anti-leu2, an anti-CD8 mAb and complement; four patients had moderate (grade 1 or 2 acute GVHD) and the only patient who experienced grade 3 manifestations was a technical failure. The control group consisted of 19 patients who received unmodified bone marrow; one patient had grade 1, 4 patients had grade 2, and 10 had grade 3 or 4 acute GVHD. The actuarial incidence of grade > or = 2 acute GVHD was 20 +/- 20% in the CD8-depleted group compared with 80 +/- 18% in the controls (P = 0.004). Death in 5 of the control patients and the single patient in whom CD8 depletion was a technical failure was related to acute GVHD. Graft failure occurred in 2 patients in the CD8-depleted group and in none of the controls. Leukemic relapse occurred in 2 patients receiving CD8-depleted bone marrow and 2 patients in the control group. Seven patients receiving marrow depleted of CD8+ cells are alive and free of leukemia and 9 patients in the control group are alive, 7 of whom remain leukemia-free (P = 0.88). The 3-year actuarial leukemia-free survival is 37 +/- 22% of the CD8-depleted group and 36 +/- 22% for the control group. These results indicate that selective depletion of CD8+ cells from the bone marrow significantly reduces the incidence and severity of acute GVHD.

Treatment of Cytomegalovirus Retinopathy with Ganciclovir

Ganciclovir is an experimental antiviral drug with activity against human cytomegalovirus (CMV). Forty patients with acquired immune deficiency syndrome (AIDS) and CMV retinopathy were treated with ganciclovir on a compassionate protocol basis. Initial treatment doses ranged from 5.0 to 14.0 mg/kg/day for 9 to 26 days. Signs of drug response were a halt to enlargement of lesions, decreased opacification of retinal tissue, and resolution of hemorrhage and vasculitis. Complete response was seen in 88% of patients and incomplete response was seen in 9%. Vision improved or remained stable in 88% of patients. Initial treatment did not eradicate live virus from the eye. To prevent reactivation of disease, 26 patients received low-dose maintenance therapy ranging from 1.5 to 7.5 mg/kg/day, once or twice daily, 3 to 7 days per week. Reactivation of disease developed for unknown reasons in 50% of patients on continuous, uninterrupted maintenance therapy for longer than 3 weeks. Reversible neutropenia, requiring cessation of treatment, developed in 30% of patients on initial treatment and in 38% of patients on maintenance therapy. Rhegmatogenous retinal detachment was a late complication in seven patients. By reducing or delaying visual loss, ganciclovir appears to be useful in the management of CMV retinopathy in patients with AIDS.

Beta-lactam antibiotic therapy in febrile granulocytopenic patients: A randomized trial comparing cefoperazone plus piperacillin, ceftazidime plus piperacillin, and imipenem alone

OBJECTIVE To compare the efficacy, toxicity, and cost-effectiveness of double beta-lactam therapy with monotherapy. DESIGN A randomized, controlled trial. PATIENTS Febrile, granulocytopenic patients (429). INTERVENTIONS Patients were randomly assigned to receive iv cefoperazone (3 g every 12 hours) plus piperacillin (75 mg/kg body weight every 6 hours), ceftazidime (2 g every 8 hours) plus piperacillin (75 mg/kg every 6 hours), or imipenem alone (1.0 g or 0.5 g every 6 hours). Patients also received prophylactic vitamin K. MEASUREMENTS Clinical improvement, eradication of the infecting organism, and toxicity in 403 evaluable patients with one or more infections. MAIN RESULTS Cefoperazone and ceftazidime, when given in combination with piperacillin, were equally effective (response rates of 75% (104 of 138 patients) and 74% (101 of 137 patients), respectively). Monotherapy with imipenem had a response rate of 82% (111 of 136 patients) and was as effective as double beta-lactam therapy. Overall antibiotic-related toxicity was minimal, although seizures were associated with high doses of imipenem. Seizures occurred in 3 of 29 patients (10.3%) who were receiving 4 g/d of imipenem, in 3 of 136 patients (2.2%) who were receiving cefoperazone plus piperacillin, in 0 of the 132 patients who were receiving ceftazidime plus piperacillin, and in 1 of 106 patients (0.9%) who were receiving 2 g/d of imipenem (P less than 0.005). The 2-g daily dose of imipenem was as effective as the 4-g daily dose. Diarrhea was more frequent in patients receiving cefoperazone, whereas nausea occurred more often with imipenem. No antibiotic-related hemorrhage or nephrotoxicity was observed. Superinfections caused by beta-lactam-resistant, gram-negative bacilli were uncommon but occurred more frequently with double beta-lactam therapy than with imipenem monotherapy (11 of 268 patients compared with 1 of 135 patients; P = 0.06). Xanthomonas maltophilia superinfections occurred only in patients receiving imipenem (3 of 135 patients compared with 0 of 268 patients; P = 0.03). Imipenem monotherapy was the least expensive therapy. CONCLUSIONS Cefoperazone and ceftazidime were equally effective when used in combination antibiotic therapy with piperacillin. Twice-daily cefoperazone is less expensive than ceftazidime given three times daily. Monotherapy with imipenem, at a daily dose of 2 g, is as efficacious as double beta-lactam therapy and costs less than combination therapy.