Impact of Adenovirus Stool PCR Screening on Incidence, Management, and Outcomes in Pediatric Hematopoietic Stem Cell Transplant Patients (HSCT)

Abstract

Introduction Adenovirus (AdV) infections can cause high morbidity and mortality. Reports that early PCR detection in stool preceded viremia led to a change in institutional screening practices. Objectives To describe the impact of AdV stool PCR screening. Methods We conducted a retrospective chart review of pediatric allo-HSCT at our institution from July 2007 – July 2018. Weekly AdV blood PCR screening was done throughout with addition of weekly stool AdV PCR screening from July 2010. Incidence rates were compared by Fisher's exact tests. Kappa statistic was used to measure agreement. Results We identified 117 transplants with 113 patients. Eight transplants were removed from analysis due to incomplete screening. Pre-stool screening AdV incidence was 6.7% (1 pneumonia,1 urine) with no deaths due to AdV. Post-stool screening AdV incidence was 31.6% (10 stool, 5 stool/blood, 5 blood, 2 respiratory, 2 stool/respiratory,1 stool/blood/respiratory) with 1 death due to AdV pneumonia despite cidofovir treatment with initial stool only detection. AdV detection was significantly increased in patients with stool testing versus blood testing alone (p=0.007) with poor agreement between the blood and stool testing (κ=0.25). Stool detection had limited value related to respiratory disease. No difference was seen in AdV incidence based on respiratory testing alone between patients with and without stool testing (p>0.9). The 2 patients with stool/respiratory AdV received cidofovir with initial stool only detection yet developed respiratory AdV. For the entire cohort, 27 patients tested positive for AdV with 68% of positive AdV patients receiving serotherapy or in vivo/ex vivo T-cell depletion (TCD). Of the patients with blood and stool testing (N=79), only 5% were stool only positive and did not have serotherapy or TCD. Stool AdV testing is $799/sample. Blood AdV testing is $383/sample. Conclusion AdV incidence was higher with the addition of stool testing. The addition of AdV stool screening however had limited impact on respiratory AdV, the cause of the one AdV-related death in our cohort. Given the high association of positive AdV in patients receiving serotherapy or TCD, a risk-targeted screening strategy may be considered for a cost-effective approach.