Sci Transl Med. 2016 May 18;8(339):339ra71. doi: 10.1126/scitranslmed.aaf2311.

Increased GVHD-related mortality with broad-spectrum antibiotic use after allogeneic hematopoietic stem cell transplantation in human patients and mice.

Shono Y¹, Docampo MD¹, Peled JU^1,^2,³, Perobelli SM¹, Velardi E^1,⁴, Tsai JJ¹, Slingerland AE¹, Smith OM¹, Young LF¹, Gupta J¹, Lieberman SR¹, Jay HV¹, Ahr KF¹, Porosnicu Rodriguez KA¹, Xu K¹, Calarfiore M¹, Poeck H¹, Caballero S¹, Devlin SM⁵, Rapaport F⁶, Dudakov JA^1,⁷, Hanash AM^2,³, Gyurkocza B^2,³, Murphy GF⁸, Gomes C⁸, Liu C⁹, Moss EL¹⁰, Falconer SB¹⁰, Bhatt AS¹⁰, Taur Y^2,¹¹, Pamer EG^1,^2,¹¹, van den Brink MRM^#^1,^2,³, Jenq RR^#^2,³.

Author information

1: Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York.
2: Weill Medical College of Cornell University, New York, New York.
3: Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
4: Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy.
5: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
6: Human Oncology & Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York.
7: Program in Immunology, Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington.
8: Program in Dermatopathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
9: Departments of Pathology and Laboratory Medicine, New Jersey Medical School and Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey.
10: Department of Medicine and Genetics, Stanford University, Stanford, California.
11: Infectious Diseases Service, Lucille Castori Center for Microbes, Inflammation & Cancer, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
#: Contributed equally

Abstract

Intestinal bacteria may modulate the risk of infection and graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Allo-HSCT recipients often develop neutropenic fever, which is treated with antibiotics that may target anaerobic bacteria in the gut. We retrospectively examined 857 allo-HSCT recipients and found that treatment of neutropenic fever with imipenem-cilastatin and piperacillin-tazobactam antibiotics was associated with increased GVHD-related mortality at 5 years (21.5% for imipenem-cilastatin-treated patients versus 13.1% for untreated patients, P = 0.025; 19.8% for piperacillin-tazobactam-treated patients versus 11.9% for untreated patients, P = 0.007). However, two other antibiotics also used to treat neutropenic fever, aztreonam and cefepime, were not associated with GVHD-related mortality (P = 0.78 and P = 0.98, respectively). Analysis of stool specimens from allo-HSCT recipients showed that piperacillin-tazobactam administration was associated with perturbation of gut microbial composition. Studies in mice demonstrated aggravated GVHD mortality with imipenem-cilastatin or piperacillin-tazobactam compared to aztreonam (P < 0.01 and P < 0.05, respectively). We found pathological evidence for increased GVHD in the colon of imipenem-cilastatin-treated mice (P < 0.05), but no difference in the concentration of short-chain fatty acids or numbers of regulatory T cells. Notably, imipenem-cilastatin treatment of mice with GVHD led to loss of the protective mucus lining of the colon (P < 0.01) and the compromising of intestinal barrier function (P < 0.05). Sequencing of mouse stool specimens showed an increase in Akkermansia muciniphila (P < 0.001), a commensal bacterium with mucus-degrading capabilities, raising the possibility that mucus degradation may contribute to murine GVHD. We demonstrate an underappreciated risk for the treatment of allo-HSCT recipients with antibiotics that may exacerbate GVHD in the colon.

PMID:: 27194729
PMCID:: PMC4991773
DOI:: 10.1126/scitranslmed.aaf2311

[Indexed for MEDLINE]

Free PMC Article

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Fig. 3

Treatment with imipenem-cilastatin in GVHD mice results in elevated numbers of donor CD4⁺ T cells, and increased production of IL-23 in the colon. (A to F) Lethally irradiated 129S1 recipients were transplanted with C57BL/6 T-cell depleted bone marrow cells with 1× 10⁶ C57BL/6 T cells. Recipients were treated with imipenem-cilastatin or aztreonam as described in . (A) Colonic lamina propria-infiltrating leukocytes from recipients were analyzed on day 21 by flow cytometry. Data are combined from two independent experiments. Values represent mean ± SEM (n = 10–14). *, P < 0.05; **, P < 0.01 by Mann-Whitney U test. (B) Concentration of IL-23 in serum, whole small intestine homogenate, and whole colon homogenate. Data are combined from two independent experiments. Values represent mean ± SEM (n = 10–12). *, P < 0.05 by Mann-Whitney U test. The individual plots in the graphs indicate individual animals sacrificed at the time of the analysis in A and B. (C) Lamina propria-infiltrating leukocytes from the colon on day 21 were enriched for CD11b and CD11c simultaneously using a mixture of magnetic beads; IL-23 transcripts were quantified by real time PCR. Data are representative of two independent experiments. Values represent mean ± SEM (n = 3). *, P < 0.05 by Mann-Whitney U test. (D) Immunofluorescence staining was used to quantify pSTAT3, CD3, and DAPI-positive cells in colonic tissue collected on day 21 (the white bar indicates 500 μm). (E) RNA sequencing analysis of the distal colon on day 16 after allo-HSCT. The top 50 regulated genes are shown in the heatmap panel. (F) Immunofluorescence staining was used to quantify CD11b, B220, and DAPI-positive cells in colonic tissue collected on day 21 (the white bar indicates 50 μm). Data are representative of two independent experiments. Values represent mean ± SEM (n = 7–8). **, P < 0.01; ***, P < 0.001; ****; P < 0.0001 in D and F by Mann-Whitney U test.

Increased GVHD-related mortality with broad-spectrum antibiotic use after allogeneic hematopoietic stem cell transplantation in human patients and mice

Sci Transl Med. ;8(339):339ra71-339ra71.

Fig. 4

Mice treated with imipenem-cilastatin in the setting of GVHD show increased abundance of Akkermansia. (A) Stool specimens obtained from mice treated with imipenem-cilastatin or aztreonam were collected on day 21 and analyzed by 16S rRNA gene sequencing (as in ), followed by principal coordinate analysis of weighted and normalized UniFrac distances. Proportion of variance accounted for by each principal component is indicated. (B and C) Differential taxonomic abundance between aztreonam treated and imipenem-cilastatin treated recipients was analyzed by (B) linear discriminate analysis coupled with effect size measurements (LEfSe) and (C) by LEfSe projected as a cladogram. Data are representative of more than five independent experiments in A to C. (D and E) Shown are comparisons of bacterial abundance at the phylogenetic levels of (D) order, and (E) genus. Data are combined from 6 independent experiments (n = 32–36). ***, P < 0.001 by multiple comparisons, corrected by Holm-Sidak test. (F to H) Stool specimens collected from mice with GVHD treated with antibiotics were collected on day 21, and evaluated by metagenomic shotgun sequence analysis. (F) Comparison of bacterial species abundance determined by taxonomy. Numbers 1 through 6 along the x-axis represent the individual subjects. (G) Principal component analysis of quantification of sequence reads from KEGG gene orthologs comparing specimens from mice treated with aztreonam and imipenem-cilastatin. (H) Quantification of gene sequences by homology was performed on stool specimens collected on day 21. Amuc_0953, a sulfatase, and Amuc_2164 a glycosyl hydrolase, are two predicted secreted mucolytic genes found in the genome of Akkermansia muciniphila ATCC BAA-835, isolated from human feces. **, P < 0.01 by Mann-Whitney U test.

Increased GVHD-related mortality with broad-spectrum antibiotic use after allogeneic hematopoietic stem cell transplantation in human patients and mice

Sci Transl Med. ;8(339):339ra71-339ra71.