S350 Abstracts / Biol Blood Marrow Transplant 25 (2019) S290 S442

It occurs most commonly at 21 to 42 days following HCT. The
clinical manifestations of BKPyV-associated hemorrhagic cysti-
tis after HCT may include cystitis, hematuria with or without
clots, renal failure due to obstruction, and rarely, life-threaten-
ing bleeding.
Objectives: We report in this case series the treatment
approach in three of our patients who developed symptomatic
infection as listed below
patient Malignancy Conditioning Donor Symptomatic
regimen infection
1 Pre B-ALL MA- CY/TBI + rATG MUD D38
2 T-Cell lymphoma RI-BU/FLU MRD Day 35
3 Mixed RI- BU/FLU MRD Day 31
phenotype AML
Method: Our treatment approach was to initiate aggressive
hydration, decrease immunosuppressive medications, and
start treatment with combination high dose cidofovir, and
IVIG. Cidofovir has a modest in vitro antiviral activity against
BKPyV, and has been widely used to treat patients with BKPyV
hemorrhagic cystitis, even though it is not FDA approved for
that indication. On the other hand, immunoglobulin prepara-
tions contain BKPyV neutralizing antibodies against all major
genotypes of BKPyV. Our patients had low immunoglobulin
level, and for that reason adding IVIG to their treatment regi-
men was considered. All three patients received the first treat-
ment with cidofovir (5 mg/kg/dose), and IVIG, immediately
after their symptoms started, and the diagnosis was confirmed.
Results: All three patients noticed significant improvement in
their symptoms after the first treatment. Patients 1, and 2,
received three treatments with weekly cidofovir, over three
weeks, while patient 3 received 2 treatments only, and the
third treatment was held due to complete resolution of the
symptoms. As shown in table 2, we can see how the BKPyV
level was trending down as the patients were receiving their
treatment; this also coincided with the improvement in their
macroscopic hematuria, the amount of blood clots in the urine,
urinary frequency and bladder spasms that they presented
with.
Infectious Diseases, Infection Control & Employee Health, MD
Anderson Cancer Center, Houston, TX; 2 Department of Infectious
Diseases, Infection Control, and Employee Health, The University
of Texas MD Anderson Cancer Center, Houston, TX; 3 1515
Holcombe Blvd, MD Anderson Cancer Center, HOUSTON, TX;
4
Division of Pharmacy, The University of Texas MD Anderson
Cancer Center, Houston, TX
Introduction: CMV infection remains a leading cause of mor-
bidity and mortality in allogeneic hematopoietic cell transplant
(allo-HCT) recipients. CMV can cause tissue-invasive disease,
especially pneumonitis, with poor outcomes.
Methods: We performed a retrospective study in HCT recipi-
ents who had CMV pneumonia from January 2014 to August
2018. The microbiology laboratory records were queried to
identify patients with CMV pneumonia based on CMV viral cul-
ture and CMV real time-PCR in bronchoalveolar lavage (BAL).
Data on demographics, clinical characteristics, management
and mortality were collected.
Results: A total of 35 patients were diagnosed with CMV pneu-
monia and 16 (47%) were male, with a median age of 56 years
(range: 18-83). The median time from HCT to CMV pneumonia
was 141 days (range 25-1579); the majority occurred after day
100 (60%). All patients except one were CMV seropositive and
15/31 (48%) had GVHD at time of diagnosis. The median
plasma CMV viral load (VL) at diagnosis was 137 UI/mL (range:
0-6.586) while the median VL in BAL was 1.700 UI/mL (range
79-64.800) (Figure). Foscarnet was the most common antiviral
agent used (23, 70%) followed by ganciclovir (16, 48%). Twenty
(61%) patients received combination therapy with IVIGs with a
mean number of doses of 4.35 (range: 1-17). All-cause mortal-
ity was 80% and CMV-associated mortality was 66%. Systemic
steroids (75%), co-infections after diagnosis of CMV pneumonia
(37%) and mechanical ventilation (82%) were associated with
mortality death.
Conclusion: CMV pneumonia remains a significant cause of
mortality after HCT and most occurred after day 100.

BK virus level (copies/mL) initial Week 1 Week 2 Week 3

1 4.00E+08 2.70E+0 1.20E+08 0
2 9.60E+07 1.40E+07 1,700,000 35,800
3 3.50E+08 210,000 0 N/A

Conclusion: BKPyV hemorrhagic cystitis is a significant cause

of morbidity, occurring in up to 20 % of stem cell transplant
recipients. At the present time treating these patients centers
around hydration, reduce immune suppression, and some-
times using cidofovir, which is still not FDA approved for this
indication. In this case series we demonstrated that starting
our three patients on combination treatment with cidofovir, Figure 1. Comparison of median CMV viral load, in plasma and BAL, by Mann-
and IVIG, helped improve their symptoms and reduce their whitney test.
BKPyV level, just after the first treatment, with complete reso-
lution of their symptoms in 2-3 weeks.

523
High Mortality of CMV Pneumonia in Hematopietic Cell
Transplant Recipients.
Marjorie V. Batista MD, TID, PhD1, Fareed Khawaja MD2,
Lynn El Haddad PhD3, Samuel L Aitken PharmD, BCPS4,
Farnaz Foolad PharmD, BCPS4,
Roy F. Chemaly MD, MPH, FIDSA, FACP2. 1 Department of
524
Human Metapneumovirus or Influenza A Upper Respiratory
Tract Infection Associated with Increased Risk of Bacterial
Superinfection in Allogeneic Hematopoietic Cell Transplant
Recipients
Chikara Ogimi MD1, Hu Xie MS2, Angela P Campbell MD, MPH3,
Alpana Waghmare MD4, Jane M Kuypers PhD5,
Keith R Jerome MD, PhD3, Jason Chien MD, MS6, Cheryl Callais7,
Guang-Shing Cheng MD8, Steven A. Pergam MD, MPH9,
 Abstracts / Biol Blood Marrow Transplant 25 (2019) S290 S442
Wendy M Leisenring PhD3, Janet A Englund MD1,
Michael J Boeckh MD, PhD9. 1 Pediatrics, University of
Washington, Seattle, WA; 2 Clinical Biostatistics, Fred Hutchinson
Cancer Research Center, Seattle, WA; 3 Fred Hutchinson Cancer
Research Center, Seattle, WA; 4 Infectious Diseases, Seattle
Children's Hospital, Seattle, WA; 5 Laboratory Medicine,
University of Washington, Seattle, WA; 6 Janssen Biopharma, Inc.,
Seattle, WA; 7 Clinical Trial Services, Inc., Covington, WA;
8
Medicine, University of Washington, Seattle, WA; 9 Vaccine and
Infectious Diseases Division, Fred Hutchinson Cancer Research
Center, Seattle, WA
Introduction: Bacterial superinfection following moderate to
severe respiratory viral infections (RVIs), especially influenza
(Flu), is well described in immunocompetent hosts. The clinical
impact of preceding RVIs on the development of bacterial
superinfection in hematopoietic cell transplant (HCT) recipi-
ents may be significant although data are limited. Furthermore,
the impact of upper respiratory tract infection (URTI) on this
outcome has not been systematically evaluated.
Objectives: To investigate whether URTI due to specific respi-
ratory viruses was associated with increased risk of developing
bacteremia or bacterial pneumonia post-HCT.
Methods: In a longitudinal surveillance study of RVIs among
allogeneic HCT recipients conducted from 2005-10, weekly
post-HCT nasal washes were collected through day 100. Nasal
and bronchoalveolar lavage samples were tested by multiplex
PCR for respiratory syncytial virus, parainfluenza viruses (PIV)
1 4, Flu A/B, human metapneumovirus (HMPV), adenovirus,
rhinoviruses and coronaviruses. URTI was defined as having
respiratory virus detected from nasal samples with respiratory
symptoms. Bacteremia and bacterial pneumonia were defined
as growth of significant bacteria (e.g., Coagulase-negative
staphylococci was defined as insignificant bacteria) from blood
and lower respiratory tract samples including bronchoalveolar
lavage, respectively. Separate Cox proportional hazards models
were used to examine associations between first URTI for indi-
vidual viruses and the subsequent development of first bacter-
emia and/or bacterial pneumonia by 100 days post-HCT.
Results: We identified 471 HCT recipients (median age:
51 years, range 8 months-75 years). Number of patients for
each first outcome event by 100 days post-HCT included the
following: Gram-positive bacteremia (n=64), Gram-negative
bacteremia (n=53), Gram-positive pneumonia (n=46), Gram-
negative pneumonia (n=8), and either bacteremia or pneumo-
nia (n=152). After adjusting for pre-transplant factors only and
S351
pre- and post-transplant factors, significant URTI variables for
outcomes in both models were (1) Flu A for gram-positive bac-
teremia, (2) HMPV for gram-positive pneumonia, and (3)
HMPV for bacteremia or bacterial pneumonia (Figure). The
association between PIV URTI and development of bacteremia
or pneumonia approached statistical significance.
Conclusion: In HCT recipients, URTIs due to Flu A and HMPV are
significant risk factors for the development of gram-positive bac-
teremia and pneumonia, respectively. Further studies are needed
to assess whether prevention or early diagnostic and treatment
strategies for RVIs can reduce the risk of bacterial infection.
525
Impact of Influenza Vaccination on Outcomes of Influenza
Infections in Immunocompromised Patients
Lea Sacca MPH1, Roy F. Chemaly MD, MPH, FIDSA, FACP2,
Marjorie V. Batista MD, TID, PhD3, Ying Jiang MS4,
Lynn El Haddad PhD2,
Ella J Ariza-Heredia MD2. 1 MPH Health Promotion Behavioral
Sciences/Global Health, University of Texas Health Science Center
Houston, Houston, TX; 2 Department of Infectious Diseases,
Infection Control, and Employee Health, The University of Texas
MD Anderson Cancer Center, Houston, TX; 3 Department of
Infectious Diseases, Infection Control & Employee Health, MD
Anderson Cancer Center, Houston, TX; 4 Department of Infectious
Diseases, Infection Control & Employee Health, The University of
Texas MD Anderson Cancer Center, Houston, TX
Introduction: Patients with cancer are more susceptible to
influenza infections than the general population, Hematopoi-
etic Cell Transplant (HCT) recipients in particular. Conflicting
data on influenza vaccine effectiveness and a lack of clear rec-
ommendations in complex clinical scenarios make the compli-
ance with immunization suboptimal.
Methods: We conducted a retrospective study and included
both HCT and non-HCT recipients with laboratory-confirmed
influenza infection during the previous flu season (September
2017- May 2018). We evaluated 365 patients with hematologic
malignancies (85), HCT recipients (138), and patients with var-
ious solid tumors (142). We analyzed the impact of influenza
vaccination on mortality.
Results: Influenza A/H3N2 was the most common type
detected during the past season with a total of 251 (69%)
patients affected and half of the patients were hospitalized.
Amongst the HCT recipients, more patients had an allogeneic
than autologous transplant (56% vs. 44%). When compared to
HCT recipients who were vaccinated, non-vaccinated HCT
recipients had higher mortality rate (21% vs. 6%, p<0.05) and
more died from respiratory failure (17% vs. 5%, p<0.05). When
stratifying HCT recipients with or without lymphopenia
Table 1
Vaccination rates among ST patients, HM patients, and HCT recipients charac-
terized by flu-type groups, administration of oseltamivirtherapy, death, and
cause of death