Abstract:
INTRODUCTION: This practice survey is conducted to analyze clinical hematopoietic stem cell transplantation (HSCT) practice variability among centers in the WHO Eastern Mediterranean Region (EMRO), as represented by the Eastern Mediterranean Blood and Marrow Transplantation (EMBMT) group. METHOD: Th is internet based survey was completed by the medical program directors of the EMBMT centers; 17 centers participated. The survey collected data on various clinical aspects of HSCT practice. RESULTS: Consistency in pre HSCT cardiac (100percent), pulmonary (82percent) and viral screen (100percent) was observed. Obtaining informed consent was universal. Pre-HSCT psychological assessment is practiced in 50percent of the centers. All centers used single-bedded rooms with HEPA filters. Visitor policy during neutropenic phase and the use of gowns, masks or gloves when examining patients varied among centers. MRSA-VRE screen and use of low bacterial diet were applied in 65percent and 82percent, respectively. Anti-bacterial prophylaxis is employed in 58percent (Auto-SCT) and 60percent (Allo-SCT) of the centers. Drug choice varied (cotrimoxazole, ciprofloxacin, levofloxacin, piperacillin-tazobactam); 60percent of the centers used penicillin prophylaxis in GVHD patients. PCP prophylaxis is applied in 58percent (Auto-SCT) and 87percent (Allo-SCT) of the centers; cotrimoxazole is usually used. Anti-viral prophylaxis with acyclovir or, less commonly, valacyclovir is used in 70percent (Auto-SCT) and 93percent (Allo-SCT) of centers. Anti-fungal prophylaxis is applied in 70percent (Auto-SCT), 93percent (myeloablative Allo-SCT) and 87percent (reduced intensity [RIC] Allo-SCT). Fluconazole is used in all Auto-SCT and majority of Allo-SCT recipients; few centers used other agents (itraconazole, voriconazole, amphotericin B) in Allo-SCT. Prophylactic GCSF use varied among centers: Auto-SCT 77percent, myeloablative Allo-SCT 33percent, RIC Allo-SCT 27percent. Use of ursodeoxycholic acid for venoocclusive disease (VOD) prophylaxis is variable: 60percent (Allo-SCT) and 12percent (Auto-SCT). Cyclosporine-methotrexate is the most commonly used GVHD prophylaxis in myeloablative Allo-SCT (93percent); heterogeneity was seen in RIC SCT. Treatment of steroid refractory acute GVHD varied (ATG 53percent, higher steroid dose 40percent). CMV monitoring varied between antigenemia (53percent) and PCR (40percent) techniques. Pre-emptive anti CMV therapy is used in 86percent of the centers, while 7percent used routine CMV prophylaxis; 7percent had no specific CMV management policy. CONCLUSION: Consistency was observed in areas of pre-SCT work up, use of single rooms, HEPA filters and GVHD prophylaxis. Heterogeneity is observed in other practice aspects including other isolation measures, antimicrobial prophylaxis, VOD prophylaxis, growth factor use and treatment of steroid refractory GVHD. Further studies are needed to probe the impact of such practice variations on post-transplant outcome and to ascertain the best clinical practice approach. © 2013, King Faisal Specialist Hospital and Research Centre. Published by Elsevier Ltd. All rights reserved.