1
|
Supriyadi E, Purwanto I, Widiastuti Z, Armytasari I, Sandi S, Ardianto B, Kaspers GJL. Infection-related mortality and infection control practices in childhood acute myeloid leukemia in a limited resource setting: Experience with the Indonesian national protocol. BELITUNG NURSING JOURNAL 2024; 10:185-191. [PMID: 38690309 PMCID: PMC11056831 DOI: 10.33546/bnj.3139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/25/2023] [Accepted: 01/28/2024] [Indexed: 05/02/2024] Open
Abstract
Background In resource-limited settings, addressing infections remains a substantial challenge in the management of children with Acute Myeloid Leukemia (AML). In Indonesia, infection-related mortality (IRM) is thought to be high compared to high-income countries. However, there has been no previous study of infection profile and IRM in Indonesian patients with AML. Objective This study aimed to describe infections and IRM in children with AML treated according to the Indonesian National AML protocol and to describe the implementation of infection control practices in resource-limited settings. Methods This retrospective observational study used secondary data from the medical records of pediatric patients with AML treated with the National Protocol at Dr. Sardjito Hospital, Yogyakarta, Indonesia, from April 2012 to September 2018. Essential patient characteristics, time of IRM, and cause of death were recorded, and infection control practices were observed. Data were analyzed using descriptive statistics. Results 113 patients with AML were treated with the National protocol, and 83 met the inclusion criteria. Infections occurred in 69 (83%) patients with a total of 123 episodes (mean 1.8/patient). Death was seen in 48 (58%) patients, with 19 (23%) IRM. The majority of infections were in the gastrointestinal tract (n = 51, 30.5%), sepsis (n = 29, 17%), and respiratory tract (n = 28, 17%). Infections mostly occurred during the first induction (41%). There were 90 (73%) episodes of clinically documented infection and 33 (27%) episodes of microbiologically documented infection. The positivity rate of blood cultures was only 27%. The majority of bacteria detected were gram-negative (n = 25, 69%), and among them were Klebsiella pneumonia (19%) and Escherichia coli (19%). Candida albicans was detected in 1 (2%) culture. Suboptimal infection prevention and control were found in the clinical practice. Conclusion Infections and infection-related mortality in children with AML treated using the National protocol were frequent, mainly occurring during the first induction phase. Compliance with infection prevention and control measures needs improvement. Urgent attention is required for better supportive care, including isolation rooms, antibiotics, and antifungals. The predominance of Gram-negative bacterial infections highlights the necessity for further research into effective prophylaxis. Enhanced healthcare and nursing professional vigilance and tailored antibiotic strategies are vital. Improving compliance and ensuring adequate supportive care resources are essential, emphasizing nursing's pivotal role. Further research is crucial to drive advancements in infection control strategies.
Collapse
Affiliation(s)
- Eddy Supriyadi
- Department of Child Health, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Ignatius Purwanto
- Department of Child Health, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | | | - Inggar Armytasari
- Department of Child Health, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | | | - Bambang Ardianto
- Department of Child Health, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Gertjan J. L. Kaspers
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Oncology, The Netherlands
| |
Collapse
|
2
|
Yun JP, Ding PQ, Dolley A, Cheung WY. Decitabine/Cedazuridine in the Management of Myelodysplastic Syndrome and Chronic Myelomonocytic Leukemia in Canada. Curr Oncol 2023; 30:8005-8018. [PMID: 37754496 PMCID: PMC10528038 DOI: 10.3390/curroncol30090581] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 09/28/2023] Open
Abstract
The management of myelodysplastic syndrome (MDS) and chronic myelomonocytic leukemia (CMML) is limited and remains an unmet need. Decitabine/cedazuridine (DEC-C, ASTX727) is Canada's first and only approved oral hypomethylating agent for MDS and CMML. We characterized the real-world use of DEC-C through a Canadian compassionate use program. Demographic and clinical data from 769 patients enrolled in Taiho Pharma Canada's Patient Support Program were collected and analyzed. These patients represent a collection period from 10 November 2020 to 31 August 2022 with a median age of 76 years. Among 651 patients who started DEC-C, the median treatment duration was 4.2 cycles. The median overall and progression-free survival were 21.6 and 10.7 months, respectively. Among 427 patients who discontinued treatment, the majority (69.5%) stopped due to death (n = 164) or disease progression (n = 133). Multivariable cox regression showed that age, province of residence, blast counts, antibiotic prophylaxis, and number of dose reductions and delays were not significantly associated with overall and progression-free survival. DEC-C is a promising alternative to parenteral hypomethylating agent therapy, and it likely addresses an important unmet need for effective and convenient therapies in this setting.
Collapse
Affiliation(s)
- John Paul Yun
- Oncology Outcomes Program, Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada; (J.P.Y.); (P.Q.D.)
- Galway University Hospital, H91 YR71 Galway, Ireland
| | - Philip Q. Ding
- Oncology Outcomes Program, Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada; (J.P.Y.); (P.Q.D.)
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Aastha Dolley
- Taiho Pharma Canada, Inc., Oakville, ON L6H 5R7, Canada;
| | - Winson Y. Cheung
- Oncology Outcomes Program, Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada; (J.P.Y.); (P.Q.D.)
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| |
Collapse
|
3
|
McMahon S, Sahasrabhojane P, Kim J, Franklin S, Chang CC, Jenq RR, Hillhouse AE, Shelburne SA, Galloway-Peña J. Contribution of the Oral and Gastrointestinal Microbiomes to Bloodstream Infections in Leukemia Patients. Microbiol Spectr 2023; 11:e0041523. [PMID: 37022173 PMCID: PMC10269818 DOI: 10.1128/spectrum.00415-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/20/2023] [Indexed: 04/07/2023] Open
Abstract
Bloodstream infections (BSIs) pose a significant mortality risk for acute myeloid leukemia (AML) patients. It has been previously reported that intestinal domination (>30% relative abundance [RA] attributed to a single taxon) with the infecting taxa often precedes BSI in stem cell transplant patients. Using 16S rRNA amplicon sequencing, we analyzed oral and stool samples from 63 AML patients with BSIs to determine the correlation between the infectious agent and microbiome composition. Whole-genome sequencing and antimicrobial susceptibilities were performed on all BSI isolates. Species-level detection of the infectious agent and presence of antibiotic resistance determinants in the stool (blaCTX-M-15, blaCTX-M-14, cfrA, and vanA) were confirmed via digital droplet PCR (ddPCR). Individuals with Escherichia coli (stool P < 0.001), Pseudomonas aeruginosa (oral P = 0.004, stool P < 0.001), and viridans group streptococci (VGS) (oral P = 0.001) bacteremia had a significantly higher relative abundance of those respective genera than other BSI patients, which appeared to be site specific. Although 78% of patients showed presence of the infectious genera in the stool and/or saliva, only 7 exhibited microbiome domination. ddPCR confirmed species specificity of the 16S data and detected the antibiotic resistance determinants found in the BSI isolates within concurrent stools. Although gastrointestinal (GI) domination by an infecting organism was not present at the time of most BSIs in AML, the pathogens, along with AMR elements, were detectable in the majority of patients. Thus, rapid genetic assessment of oral and stool samples for the presence of potential pathogens and AMR determinants might inform personalized therapeutic approaches in immunocompromised patients with suspected infection. IMPORTANCE A major cause of mortality in hematologic malignancy patients is BSI. Previous studies have demonstrated that bacterial translocation from the GI microbiome is a major source of BSIs and is often preceded by increased levels of the infectious taxa in the GI (>30% abundance by 16S rRNA sequencing). In this study, we sought to better understand how domination and abundance levels of the oral and gut microbiome relate to bacteremia occurrence in acute myeloid leukemia patients. We conclude that analyses of both oral and stool samples can help identify BSI and antimicrobial resistance determinants, thus potentially improving the timing and tailoring of antibiotic treatment strategies for high-risk patients.
Collapse
Affiliation(s)
- Stephanie McMahon
- Interdisciplinary Genetics Program, Texas A&M University, College Station, Texas, USA
| | - Pranoti Sahasrabhojane
- Department of Infectious Diseases, Infection Control, and Employee Health, MD Anderson Cancer Center, Houston, Texas, USA
| | - Jiwoong Kim
- Department of Bioinformatics and Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Samantha Franklin
- Interdisciplinary Genetics Program, Texas A&M University, College Station, Texas, USA
| | - Chia-Chi Chang
- Department of Genomic Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert R. Jenq
- Department of Genomic Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Andrew E. Hillhouse
- Department of Veterinary Pathobiology, Texas A&M University, College Station, Texas, USA
- Texas A&M Institute for Genome Sciences & Society, Texas A&M University, College Station, Texas, USA
| | - Samuel A. Shelburne
- Department of Infectious Diseases, Infection Control, and Employee Health, MD Anderson Cancer Center, Houston, Texas, USA
- Department of Genomic Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Jessica Galloway-Peña
- Interdisciplinary Genetics Program, Texas A&M University, College Station, Texas, USA
- Department of Genomic Medicine, MD Anderson Cancer Center, Houston, Texas, USA
- Department of Veterinary Pathobiology, Texas A&M University, College Station, Texas, USA
| |
Collapse
|
4
|
Guarana M, Nucci M. Should patients with acute myeloid leukemia treated with venetoclax-based regimens receive antifungal prophylaxis? Leuk Res 2023; 131:107341. [PMID: 37327641 DOI: 10.1016/j.leukres.2023.107341] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/18/2023]
Abstract
Invasive fungal disease (IFD) is a major complication in patients with acute myeloid leukemia (AML) receiving intensive induction chemotherapy, and the use of anti-mold prophylaxis is considered standard of care. On the other hand, the use of anti-mold prophylaxis in AML patients receiving less-intensive venetoclax-based regimens is not well established, basically because the incidence of IFD may not be high enough to justify primary antifungal prophylaxis. Furthermore, dose adjustments in venetoclax are needed because of drug interactions with azoles. Finally, the use of azoles is associated with toxicity, including liver, gastrointestinal and cardiac (QT prolongation) toxicity. In a setting of low incidence of invasive fungal disease, the number needed to harm would be higher than the number needed to treat. In this paper we review the risk factors for IFD in AML patients receiving intensive chemotherapeutic regimens, the incidence and risk factors for IFD in patients receiving hypomethylating agents alone, and in patients receiving less-intensive venetoclax-based regimens. We also discuss potential problems with the concomitant use of azoles, and present our perspective on how to manage AML patients receiving venetoclax-based regimens without primary antifungal prophylaxis.
Collapse
Affiliation(s)
- Mariana Guarana
- University Hospital, Universidade Federal do Rio de Janeiro, Brazil
| | - Marcio Nucci
- University Hospital, Universidade Federal do Rio de Janeiro, Brazil; Grupo Oncoclínicas, Brazil.
| |
Collapse
|
5
|
Stempel JM, Podoltsev NA, Dosani T. Supportive Care for Patients With Myelodysplastic Syndromes. Cancer J 2023; 29:168-178. [PMID: 37195773 DOI: 10.1097/ppo.0000000000000661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
ABSTRACT Myelodysplastic syndromes are a heterogeneous group of bone marrow disorders characterized by ineffective hematopoiesis, progressive cytopenias, and an innate capability of progressing to acute myeloid leukemia. The most common causes of morbidity and mortality are complications related to myelodysplastic syndromes rather than progression to acute myeloid leukemia. Although supportive care measures are applicable to all patients with myelodysplastic syndromes, they are especially essential in patients with lower-risk disease who have a better prognosis compared with their higher-risk counterparts and require longer-term monitoring of disease and treatment-related complications. In this review, we will address the most frequent complications and supportive care interventions used in patients with myelodysplastic syndromes, including transfusion support, management of iron overload, antimicrobial prophylaxis, important considerations in the era of COVID-19 (coronavirus infectious disease 2019), role of routine immunizations, and palliative care in the myelodysplastic syndrome population.
Collapse
|
6
|
Tober R, Schnetzke U, Fleischmann M, Yomade O, Schrenk K, Hammersen J, Glaser A, Thiede C, Hochhaus A, Scholl S. Impact of treatment intensity on infectious complications in patients with acute myeloid leukemia. J Cancer Res Clin Oncol 2023; 149:1569-1583. [PMID: 35583829 PMCID: PMC10020242 DOI: 10.1007/s00432-022-03995-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Infectious complications reflect a major challenge in the treatment of patients with acute myeloid leukemia (AML). Both induction chemotherapy and epigenetic treatment with hypomethylating agents (HMA) are associated with severe infections, while neutropenia represents a common risk factor. Here, 220 consecutive and newly diagnosed AML patients were analyzed with respect to infectious complications dependent on treatment intensity and antifungal prophylaxis applied to these patients. PATIENTS AND METHODS We retrospectively analyzed 220 patients with newly diagnosed AML at a tertiary care hospital between August 2016 and December 2020. The median age of AML patients undergoing induction chemotherapy (n = 102) was 61 years (25-76 years). Patients receiving palliative AML treatment (n = 118) had a median age of 75 years (53-91 years). We assessed the occurrence of infectious complication including the classification of pulmonary invasive fungal disease (IFD) according to the EORTC/MSG criteria at diagnosis and until day 100 after initiation of AML treatment. Furthermore, admission to intensive care unit (ICU) and subsequent outcome was analyzed for both groups of AML patients, respectively. RESULTS AML patients subsequently allocated to palliative AML treatment have a significantly higher risk of pneumonia at diagnosis compared to patients undergoing induction chemotherapy (37.3% vs. 13.7%, P < 0.001) including a higher probability of atypical pneumonia (22.0% vs. 10.8%, P = 0.026). Furthermore, urinary tract infections are more frequent in the palliative subgroup at the time of AML diagnosis (5.1% vs. 0%, P = 0.021). Surprisingly, the incidence of pulmonary IFD is significantly lower after initiation of palliative AML treatment compared to the occurrence after induction chemotherapy (8.4% vs. 33.3%, P < 0.001) despite only few patients of the palliative treatment group received Aspergillus spp.-directed antifungal prophylaxis. The overall risk for infectious complications at AML diagnosis is significantly higher for palliative AML patients at diagnosis while patients undergoing induction chemotherapy have a significantly higher risk of infections after initiation of AML treatment. In addition, there is a strong correlation between the occurrence of pneumonia including atypical pneumonia and pulmonary IFD and the ECOG performance status at diagnosis in the palliative AML patient group. Analysis of intensive care unit (ICU) treatment (e.g. in case of sepsis or pneumonia) for both subgroups reveals a positive outcome in 10 of 15 patients (66.7%) with palliative AML treatment and in 15 of 18 patients (83.3%) receiving induction chemotherapy. Importantly, the presence of infections and the ECOG performance status at diagnosis significantly correlate with the overall survival (OS) of palliative AML patients (315 days w/o infection vs. 69 days with infection, P 0.0049 and 353 days for ECOG < 1 vs. 50 days for ECOG > 2, P < 0.001, respectively) in this intent-to-treat analysis. CONCLUSION The risk and the pattern of infectious complications at diagnosis and after initiation of AML therapy depends on age, ECOG performance status and subsequent treatment intensity. A comprehensive diagnostic work-up for identification of pulmonary IFD is indispensable for effective treatment of pneumonia in AML patients. The presence of infectious complications at diagnosis contributes to an inferior outcome in elderly AML patients.
Collapse
Affiliation(s)
- Romy Tober
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Ulf Schnetzke
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Maximilian Fleischmann
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Olaposi Yomade
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Karin Schrenk
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Jakob Hammersen
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Anita Glaser
- Institut Für Humangenetik, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Christian Thiede
- Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Andreas Hochhaus
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Sebastian Scholl
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany.
| |
Collapse
|
7
|
Kirkizlar TA, Kirkizlar O, Demirci U, Umut A, Iflazoglu H, Umit EG, Demir AM. Incidence and predisposing factors of infection in patients treated with hypomethylating agents. Leuk Res 2023; 127:107043. [PMID: 36801588 DOI: 10.1016/j.leukres.2023.107043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE Hypomethylating agents may have adverse effects such as cytopenias, cytopenia associated infections and fatality due to infections despite their favorable effects in the treatment of acute myeloid leukemia (AML), myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML). The infection prophylaxis approach is based on expert opinions and real-life experiences. Hence, we aimed to reveal the frequence of infections, predisposing factors of infection and to analyse infection attributable mortality in patients with high-risk MDS, CMML and AML who received hypomethylating agents in our center where routine infection prophylaxis is not applied. MATERIAL-METHOD 43 adult patients with AML or high-risk MDS or CMML who received HMA ≥ 2 consecutive cycles from January 2014 to December 2020 were enrolled in the study. RESULTS 43 patients and 173 treatment cycles were analyzed. The median age was 72 years and 61.3 % of patients were males. The distribution of the patients' diagnoses was; AML in 15 patients (34.9 %), high risk MDS in 20 patients (46.5 %), AML with myelodysplasia-related changes in 5 patients (11.6 %) and CMML in 3 patients (7 %). 38 infection events (21.9 %) occurred in 173 treatment cycles. 86.9 % (33 cycles) and 2.6 % (1 cycle) of infected cycles were bacterial and viral infections, respectively and 10.5 % (4 cycles) were bacterial and fungal concurrently. The most common origin of the infection was respiratory system. Hemoglobin count was lower and CRP level was higher at the beginning of the infected cycles significantly (p values were 0.002 and 0.012, respectively). Requirement of red blood cell and platelet transfusions were found to be significantly increased in the infected cycles (p values were 0.000 and 0.001, respectively). While > 4 cycles of treatment and increased platelet count were found to be protective against infection, > 6 points of Charlson Comorbidity Index (CCI) were found to increase the risk of infection. The median survival was 7.8 months in non-infected cycles while 6.83 months in infected cycles. This difference was not statistically significant (p value was 0.077). DISCUSSION The prevention and management of infections and infection-related deaths in patients treated with HMAs is crucial. Therefore, patients with a lower platelet count or a CCI score of > 6 may be candidates for infection prophylaxis when exposed to HMAs.
Collapse
Affiliation(s)
| | - Onur Kirkizlar
- Trakya University Medical Faculty, Department of Hematology, Edirne, Turkey.
| | - Ufuk Demirci
- Trakya University Medical Faculty, Department of Hematology, Edirne, Turkey.
| | - Aytug Umut
- Trakya University Medical Faculty, Department of Internal Medicine, Edirne, Turkey.
| | - Huseyin Iflazoglu
- Trakya University Medical Faculty, Department of Internal Medicine, Edirne, Turkey.
| | - Elif Gulsum Umit
- Trakya University Medical Faculty, Department of Hematology, Edirne, Turkey.
| | | |
Collapse
|
8
|
Wang ST, Chou CH, Chen TT, Lin CC, Bai LY, Yeh SP, Ho MW, Lien MY. High rate of invasive fungal infections during early cycles of azacitidine for patients with acute myeloid leukemia. Front Cell Infect Microbiol 2022; 12:1012334. [PMID: 36530436 PMCID: PMC9748082 DOI: 10.3389/fcimb.2022.1012334] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/07/2022] [Indexed: 12/05/2022] Open
Abstract
Background Acute myeloid leukemia (AML) is a form of cancer that is characterized by infiltration of the bone marrow, blood, and other tissues by proliferative, clonal, abnormally differentiated, and occasionally poorly differentiated cells of the hematopoietic system. Patients with acute myeloid leukemia (AML) receiving azacitidine (AZA) alone or in combination with venetoclax (VEN-AZA) are at increased risk for invasive fungal infections (IFIs). We compared the incidence and risk of IFI during these treatment regimens in a single Taiwan hospital. Materials and methods A total of 61 patients with AML received at least one course of AZA in the hematology ward of China Medical University Hospital (Taichung, Taiwan) between September 2012 and June 2020. Thirty-eight patients (62.3%) received AZA monotherapy; 23 (37.7%) received VEN-AZA. Results Incidence rates of probable and proven IFI were 18% and 1.6%, respectively, during AZA treatment. One proven case of Fusarium spp. infection was isolated by skin and soft tissue culture. Most (75%) IFI cases occurred during the first cycle of AZA therapy. Half of all IFI cases occurred in patients with prolonged neutropenia. The risk of IFI was significantly higher for the European LeukemiaNet (ELN) nonfavorable-risk group (intermediate- and adverse-risk group) versus the ELN favorable-risk group and for patients with prolonged neutropenia versus those without (P<0.05 for both comparisons). In this study, median OS did not differ significantly between patients with and without IFIs during AZA-containing regimens (14.6 months vs 13.7 months; P=0.59). Conclusion The incidence of IFI was high in this AML cohort treated with AZA-containing regiments in Taiwan. The majority of IFI cases occurred during the early cycles of AZA (cycles 1-2). Prospective studies are needed to determine the optimal choice of antifungal prophylaxis agent during VEN-AZA therapy for AML.
Collapse
Affiliation(s)
- Sing-Ting Wang
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Huei Chou
- Division of Infection Disease, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Tzu-Ting Chen
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Ching-Chan Lin
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Li-Yuan Bai
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan,Department of Internal Medicine, Graduate Institute of Clinical Medicine, China Medical University, Taichung, Taiwan
| | - Shih-Peng Yeh
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan,Department of Internal Medicine, Graduate Institute of Clinical Medicine, China Medical University, Taichung, Taiwan
| | - Mao-Wang Ho
- Division of Infection Disease, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Ming-Yu Lien
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan,Graduate Institute of Basic Medical Science, China Medical University, Taichung, Taiwan,*Correspondence: Ming-Yu Lien,
| |
Collapse
|
9
|
Rozema J, Hoogendoorn M, Potma I, ten Seldam I, Veeger NJGM, Kibbelaar RE, van de Loosdrecht AA, van Roon EN. Increased prescription rate of anti‐infective agents after diagnosis of myelodysplastic syndromes. EJHAEM 2022; 3:775-784. [PMID: 36051088 PMCID: PMC9422012 DOI: 10.1002/jha2.422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 12/21/2022]
Abstract
The a priori risk for infections in patients with myelodysplastic syndromes (MDS) is unknown. This study examines prescription rates of anti‐infective agents in MDS patients before and after diagnosis, in both in‐ and outpatient settings, to provide information on infection management in clinical practice. We performed a population‐based study using the HemoBase registry, containing data of all MDS patients diagnosed since 2005 in Friesland, the Netherlands. Community and hospital pharmacies provided prescription data from 1995 to 2020. Data were obtained for 203 of 292 patients (70%). Patients received significantly more anti‐infective agents, predominantly antibacterials (70%), after diagnosis compared to before: 148.7 defined daily dose/1000 days (DID) (95% CI: 146.9–150.5) and 55.1 DID (95% CI: 54.5–55.8, p < 0.01), respectively, corresponding to median 23.5 and 7.6 treatment days/year. Higher‐risk (449.9 DID) and lower‐risk patients (129.1 DID) both received significantly more anti‐infective agents after diagnosis; comorbidities, neutropenia, and age did not show significant differences relative to prescription rates. Before diagnosis, 10% of patients had infection‐related hospital admissions versus 38% after diagnosis. In conclusion, MDS patients received significantly more anti‐infective agents compared to before diagnosis. This is the first study that has quantified the prescription rate of anti‐infective agents within and beyond the clinical setting in MDS.
Collapse
Affiliation(s)
- Johanne Rozema
- Unit of Pharmacotherapy Epidemiology and Economics Department of Pharmacy University of Groningen Groningen The Netherlands
- Department of Clinical Pharmacy and Pharmacology Medical Centre Leeuwarden Leeuwarden The Netherlands
| | - Mels Hoogendoorn
- Department of Internal Medicine Medical Centre Leeuwarden Leeuwarden The Netherlands
| | - Iris Potma
- Unit of Pharmacotherapy Epidemiology and Economics Department of Pharmacy University of Groningen Groningen The Netherlands
| | - Inge ten Seldam
- Unit of Pharmacotherapy Epidemiology and Economics Department of Pharmacy University of Groningen Groningen The Netherlands
| | - Nic J. G. M. Veeger
- Science Bureau Medical Centre Leeuwarden Leeuwarden The Netherlands
- Department of Epidemiology University of Groningen University Medical Centre Groningen Groningen The Netherlands
| | | | | | - Eric N. van Roon
- Unit of Pharmacotherapy Epidemiology and Economics Department of Pharmacy University of Groningen Groningen The Netherlands
- Department of Clinical Pharmacy and Pharmacology Medical Centre Leeuwarden Leeuwarden The Netherlands
| | | |
Collapse
|
10
|
Stemler J, de Jonge N, Skoetz N, Sinkó J, Brüggemann RJ, Busca A, Ben-Ami R, Ráčil Z, Piechotta V, Lewis R, Cornely OA. Antifungal prophylaxis in adult patients with acute myeloid leukaemia treated with novel targeted therapies: a systematic review and expert consensus recommendation from the European Hematology Association. THE LANCET HAEMATOLOGY 2022; 9:e361-e373. [DOI: 10.1016/s2352-3026(22)00073-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 12/24/2022]
|
11
|
Boccia R, Glaspy J, Crawford J, Aapro M. OUP accepted manuscript. Oncologist 2022; 27:625-636. [PMID: 35552754 PMCID: PMC9355811 DOI: 10.1093/oncolo/oyac074] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/24/2022] [Indexed: 11/14/2022] Open
Abstract
Neutropenia and febrile neutropenia (FN) are common complications of myelosuppressive chemotherapy. This review provides an up-to-date assessment of the patient and cost burden of chemotherapy-induced neutropenia/FN in the US, and summarizes recommendations for FN prophylaxis, including the interim guidance that was recommended during the coronavirus disease 2019 (COVID-19) pandemic. This review indicates that neutropenia/FN place a significant burden on patients in terms of hospitalizations and mortality. Most patients with neutropenia/FN presenting to the emergency department will be hospitalized, with an average length of stay of 6, 8, and 10 days for elderly, pediatric, and adult patients, respectively. Reported in-hospital mortality rates for neutropenia/FN range from 0.4% to 3.0% for pediatric patients with cancer, 2.6% to 7.0% for adults with solid tumors, and 7.4% for adults with hematologic malignancies. Neutropenia/FN also place a significant cost burden on US healthcare systems, with average costs per neutropenia/FN hospitalization estimated to be up to $40 000 for adult patients and $65 000 for pediatric patients. Evidence-based guidelines recommend prophylactic granulocyte colony-stimulating factors (G-CSFs), which have been shown to reduce FN incidence while improving chemotherapy dose delivery. Availability of biosimilars may improve costs of care. Efforts to decrease hospitalizations by optimizing outpatient care could reduce the burden of neutropenia/FN; this was particularly pertinent during the COVID-19 pandemic since avoidance of hospitalization was needed to reduce exposure to the virus, and resulted in the adaptation of recommendations to prevent FN, which expanded the indications for G-CSF and/or lowered the threshold of use to >10% risk of FN.
Collapse
Affiliation(s)
- Ralph Boccia
- Center for Cancer and Blood Disorders, Bethesda, MD, USA
| | - John Glaspy
- UCLA School of Medicine, Los Angeles, CA, USA
| | - Jeffrey Crawford
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Matti Aapro
- Corresponding author: Matti Aapro, Cancer Centre, Clinique de Genolier, Case Postale (PO Box) 100, Route du Muids 3, 1272 Genolier, Switzerland. Tel: +41 22 3669136;
| |
Collapse
|
12
|
Sweet K, Bhatnagar B, Döhner H, Donnellan W, Frankfurt O, Heuser M, Kota V, Liu H, Raffoux E, Roboz GJ, Röllig C, Showel MM, Strickland SA, Vives S, Tang S, Unger TJ, Joshi A, Shen Y, Alvarez MJ, Califano A, Crochiere M, Landesman Y, Kauffman M, Shah J, Shacham S, Savona MR, Montesinos P. A 2:1 randomized, open-label, phase II study of selinexor vs. physician's choice in older patients with relapsed or refractory acute myeloid leukemia. Leuk Lymphoma 2021; 62:3192-3203. [PMID: 34323164 DOI: 10.1080/10428194.2021.1950706] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Selinexor, a selective inhibitor of nuclear export, has demonstrated promising activity in patients with acute myeloid leukemia (AML). This randomized, phase II study evaluated selinexor 60 mg twice weekly (n = 118) vs. physician's choice (PC) treatment (n = 57) in patients aged ≥60 years with relapsed/refractory (R/R) AML. The primary outcome was overall survival (OS). Median OS did not differ significantly for selinexor vs. PC (3.2 vs. 5.6 months; HR = 1.18 [95% CI: 0.79-1.75]; p = 0.422). Complete remission (CR) plus CR with incomplete hematologic recovery trending in favor of selinexor occurred in a minority of patients. Selinexor treated patients had an increased incidence of adverse events. The most common grade ≥3 adverse events were thrombocytopenia, febrile neutropenia, anemia, hyponatremia. Despite well-balanced baseline characteristics, there were numerically higher rates of TP53 mutations, prior myelodysplastic syndrome, and lower absolute neutrophil counts in the selinexor group; warranting further investigation of selinexor in more carefully stratified R/R AML patients.Registered trial: NCT02088541.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Susana Vives
- ICO Badalona-Hospital Germans Trias i Pujol, Badalona, Spain
| | | | | | | | - Yao Shen
- DarwinHealth Inc, New York, NY, USA
| | - Mariano J Alvarez
- DarwinHealth Inc, New York, NY, USA.,Columbia University, New York, NY, USA
| | | | | | | | | | - Jatin Shah
- Karyopharm Therapeutics, Newton, MA, USA
| | | | | | - Pau Montesinos
- Departamento de Hematologia, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,CIBERONC, Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
13
|
Bouligny IM, Mehta V, Isom S, Ellis LR, Bhave RR, Howard DS, Lyerly S, Manuel M, Dralle S, Powell BL, Pardee TS. Efficacy of 10-day decitabine in acute myeloid leukemia. Leuk Res 2021; 103:106524. [PMID: 33640708 DOI: 10.1016/j.leukres.2021.106524] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
The azanucleotide decitabine is used in the treatment of acute myeloid leukemia (AML). Studies have shown conflicting results with 10-day regimens used in previously untreated AML patients. Additionally, there is little data on 10-day decitabine regimens in the relapsed setting. This study investigated outcomes of 108 adult patients with AML in the upfront and relapsed setting treated with a 10-day decitabine regimen. In the upfront group, the overall response rate (ORR, CR + CRi) was 36.1% and the median overall survival (OS) was 6.6 months, while the relapsed/refractory group had an ORR of 25% with an OS of 4.8 months. When analyzed with respect to cytogenetics, the upfront group featured an ORR of 28.1% with an OS of 9.4 months in the intermediate cytogenetic cohort compared to a 40.5% ORR and an OS of 5.4 months in the unfavorable cytogenetic cohort. An analysis of the relapsed/refractory group demonstrated an ORR of 26.3% with an OS of 7.9 months for intermediate cytogenetics versus 25.0% with an OS of 1.8 months in the unfavorable cohort. While these response rates are similar to previously published data, the median OS appears shorter.
Collapse
Affiliation(s)
- Ian M Bouligny
- Comprehensive Cancer Center of Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Vivek Mehta
- Comprehensive Cancer Center of Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Scott Isom
- Comprehensive Cancer Center of Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Leslie R Ellis
- Comprehensive Cancer Center of Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Rupali R Bhave
- Comprehensive Cancer Center of Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Dianna S Howard
- Comprehensive Cancer Center of Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Susan Lyerly
- Comprehensive Cancer Center of Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Megan Manuel
- Comprehensive Cancer Center of Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Sarah Dralle
- Comprehensive Cancer Center of Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Bayard L Powell
- Comprehensive Cancer Center of Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Timothy S Pardee
- Comprehensive Cancer Center of Wake Forest Baptist Health, Winston-Salem, NC 27157, USA.
| |
Collapse
|
14
|
Peseski AM, McClean M, Green SD, Beeler C, Konig H. Management of fever and neutropenia in the adult patient with acute myeloid leukemia. Expert Rev Anti Infect Ther 2020; 19:359-378. [PMID: 32892669 DOI: 10.1080/14787210.2020.1820863] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Febrile neutropenia represents one of the most common treatment-associated complications in the management of acute myeloid leukemia (AML) and is considered an oncologic emergency. Rapid and detailed workup as well as the initiation of empiric broad-spectrum antibiotic therapy are critical to avoid sepsis and to reduce mortality. Although a definitive source of infection is frequently not identified, the severely immunosuppressed status of the AML patient undergoing cytotoxic therapy results in a high risk for a wide array of bacterial, fungal, and viral etiologies. AREAS COVERED The authors herein review the diagnostic and therapeutic approach to the neutropenic leukemia patient based on the current knowledge. Special consideration is given to the rapidly changing therapeutic landscape in AML, creating new challenges in the management of infectious complications. EXPERT OPINION Multidrug-resistant organisms pose a major challenge in the management of neutropenic fever patients with hematologic malignancies - including AML. Future directions to improve outcomes demand innovative treatment approaches as well as advances in biomarker research to facilitate diagnosis and disease monitoring. Recent achievements in AML-targeted therapy led to an increased incidence of differentiation syndrome, a potentially life-threatening side effect that frequently resembles clinical infection and requires prompt recognition and aggressive intervention.
Collapse
Affiliation(s)
- Andrew M Peseski
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mitchell McClean
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Steven D Green
- Melvin and Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cole Beeler
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Heiko Konig
- Melvin and Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
15
|
Ozga M, Huang Y, Blachly JS, Grieselhuber NR, Wall S, Larkin K, Haque T, Walker AR, Bhatnagar B, Behbehani G, Vasu S, Maakaron JE, Lustberg M, Mims AS. The Incidence of Invasive Fungal Infections in Patients With AML Treated With a Hypomethylating Agent. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 21:e76-e83. [PMID: 32921593 DOI: 10.1016/j.clml.2020.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Newly diagnosed patients with acute myeloid leukemia (AML) who receive induction with a hypomethylating agent (HMA) are often neutropenic with an increased risk for invasive fungal infections (IFIs). This study analyzed the incidence and risk factors for IFIs in these patients, evaluated clinical patterns in antifungal prophylaxis, and assessed the diagnostic utility of tests in this setting. PATIENTS AND METHODS We studied 117 newly diagnosed patients with AML treated with HMAs at our center, divided into groups based on concern for IFI (cIFI: all possible, probable, and proven IFIs) versus no concern for IFI. The Fisher exact test compared patients with cIFI versus without, and a multivariable logistic regression model estimated odds for cIFI. RESULTS Sixty-seven (57%) patients had cIFI, with 48 possible IFIs, 17 probable, and 2 proven cases. There was no difference in incidence based on home zip code, but the presence of chronic obstructive pulmonary disease was highly associated with cIFI (P = .001), as was male gender (P = .01). Neutropenia at treatment initiation was borderline in significance (P = .08). In diagnostics, 9% of patients had positive serum fungal markers, and 30 patients underwent bronchoscopy, with only 27% of cases yielding positive results. There was a difference in treatment regimens between patients receiving antifungal prophylaxis with mold coverage versus without mold coverage with respect to cIFI (P = .04). CONCLUSIONS cIFI in patients with AML treated with HMAs remains significant, especially in males and those with chronic obstructive pulmonary disease, who were found to be at higher risk. This may prompt clinicians to consider anti-mold prophylaxis in this setting.
Collapse
Affiliation(s)
- Michael Ozga
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ying Huang
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - James S Blachly
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Nicole R Grieselhuber
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Sarah Wall
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Karilyn Larkin
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Tamanna Haque
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Alison R Walker
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Bhavana Bhatnagar
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Gregory Behbehani
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Sumithira Vasu
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Mark Lustberg
- Division of Infectious Disease, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Alice S Mims
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH.
| |
Collapse
|
16
|
D'Angelo CR, Hall A, Woo KM, Kim K, Longo W, Hematti P, Callander N, Kenkre VP, Mattison R, Juckett M. Decitabine induction with myeloablative conditioning and allogeneic hematopoietic stem cell transplantation in high-risk patients with myeloid malignancies is associated with a high rate of infectious complications. Leuk Res 2020; 96:106419. [PMID: 32683127 DOI: 10.1016/j.leukres.2020.106419] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/17/2020] [Accepted: 07/07/2020] [Indexed: 12/21/2022]
Abstract
Patients with high-risk myelodysplastic syndrome or acute myeloid leukemia have an increased risk of death following allogeneic hematopoietic stem cell transplantation (allo-HSCT). Decitabine has minimal non-hematologic toxicity and proven efficacy in myeloid diseases, and post-transplant cyclophosphamide (PTCy) has reduced rates of graft-versus-host-disease (GVHD). We hypothesized that decitabine induction with allo-HSCT and PTCy would improve outcomes in a high-risk myeloid disease population. We performed a phase-II trial of decitabine at 20 mg/m2 for 10 days followed by allo-HSCT using a myeloablative regimen of fludarabine, IV busulfan and 4 Gy total body irradiation with PTCy for GVHD prophylaxis. Twenty patients underwent decitabine induction and 17 patients proceeded to transplant per protocol. Median overall survival from decitabine induction was 210 days (95 % CI 122-not reached). All patients developed grade 4 neutropenia after decitabine, eleven patients (55 %) developed grade 3-4 infections, and 5 cases were fatal. There were 5/20 (25 %) long-term survivors with a median follow-up of 3.6 years. Decitabine induction followed by myeloablative allo-HSCT in a high-risk population was associated with a high risk of infection and mortality related to enhanced immunosuppression. Further exploration of decitabine conditioning on reduced intensity platforms and improved infectious prophylaxis and screening may better mitigate toxicity (ClinicalTrials.gov (NCT01707004)).
Collapse
Affiliation(s)
- Christopher R D'Angelo
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Aric Hall
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kaitlin M Woo
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - KyungMann Kim
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Walter Longo
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Peiman Hematti
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Natalie Callander
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Vaishalee P Kenkre
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ryan Mattison
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mark Juckett
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| |
Collapse
|
17
|
Mohyuddin GR, Abbasi S, Ripp J, Singh A, Kambhampati S, McClune B. Patients with leukemia dying in the hospital: results of the national inpatient sample and a call to do better. Leuk Lymphoma 2020; 61:2760-2762. [PMID: 32552301 DOI: 10.1080/10428194.2020.1780585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
| | - Saqib Abbasi
- Hematology-Oncology Fellowship, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Jacob Ripp
- Department of Internal Medicine, University of Kansas, Kansas City, KS, USA
| | - Anurag Singh
- Department of Hematological Malignancies and Cellular Therapeutic, University of Kansas, Kansas City, KS, USA
| | | | - Brian McClune
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
18
|
Zając-Spychała O, Skalska-Sadowska J, Wachowiak J, Szmydki-Baran A, Hutnik Ł, Matysiak M, Pierlejewski F, Młynarski W, Czyżewski K, Dziedzic M, Wysocki M, Zalas-Więcek P, Bartnik M, Ociepa T, Urasiński T, Małas Z, Badowska W, Gamrot-Pyka Z, Woszczyk M, Tomaszewska R, Szczepański T, Irga-Jaworska N, Drożyńska E, Urbanek-Dądela A, Karolczyk G, Płonowski M, Krawczuk-Rybak M, Frączkiewicz J, Salamonowicz M, Chybicka A, Stolpa W, Sobol-Milejska G, Chełmecka-Wiktorczyk L, Balwierz W, Zak I, Gryniewicz-Kwiatkowska O, Gietka A, Dembowska-Bagińska B, Semczuk K, Dzierżanowska-Fangrat K, Musiał J, Chaber R, Kowalczyk J, Styczyński J. Infections in children with acute myeloid leukemia: increased mortality in relapsed/refractory patients. Leuk Lymphoma 2019; 60:3028-3035. [PMID: 31132917 DOI: 10.1080/10428194.2019.1616185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The aim of this nationwide study was to describe the epidemiology and profile of bacterial infections (BI), invasive fungal disease (IFD) and viral infections (VI) in patients with de novo and relapsed/refractory (rel/ref) acute myeloid leukemia (AML). Within the studied group of 250 children with primary AML, at least one infectious complication (IC) was diagnosed in 76.0% (n = 190) children including 85.1% (n = 504) episodes of BI, 8.3% (n = 49) - IFD and 6.6% (n = 39) - VI. Among 61 patients with rel/ref AML, at least one IC was found in 67.2% (n = 41) of children including 78.8% (n = 78) of BI, 14.1% (n = 14) of IFD and 7.1% (n = 7) of VI. In all AML patients, within BI Gram-negative strains were predominant. Half of these strains were multi-drug resistant. Characteristics of IFD and VI were comparable for de novo and rel/ref AML. The infection-related mortality was significantly higher, while survival from infection was significantly lower in patients with rel/ref disease.
Collapse
Affiliation(s)
- Olga Zając-Spychała
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - Jolanta Skalska-Sadowska
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - Anna Szmydki-Baran
- Department of Pediatric Hematology and Oncology, Medical University, Warszawa, Poland
| | - Łukasz Hutnik
- Department of Pediatric Hematology and Oncology, Medical University, Warszawa, Poland
| | - Michał Matysiak
- Department of Pediatric Hematology and Oncology, Medical University, Warszawa, Poland
| | - Filip Pierlejewski
- Department of Pediatric Oncology, Hematology and Diabetology, Medical University, Lodz, Poland
| | - Wojciech Młynarski
- Department of Pediatric Oncology, Hematology and Diabetology, Medical University, Lodz, Poland
| | - Krzysztof Czyżewski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Magdalena Dziedzic
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Mariusz Wysocki
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Patrycja Zalas-Więcek
- Department of Microbiology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Magdalena Bartnik
- Department of Pediatrics and Oncology, Pomeranian Medical University, Szczecin, Poland
| | - Tomasz Ociepa
- Department of Pediatrics and Oncology, Pomeranian Medical University, Szczecin, Poland
| | - Tomasz Urasiński
- Department of Pediatrics and Oncology, Pomeranian Medical University, Szczecin, Poland
| | - Zofia Małas
- Division of Pediatric Hematology and Oncology, Children Hospital, Olsztyn, Poland
| | - Wanda Badowska
- Division of Pediatric Hematology and Oncology, Children Hospital, Olsztyn, Poland
| | - Zuzanna Gamrot-Pyka
- Division of Pediatric Hematology and Oncology, Chorzow Pediatric and Oncology Center, Chorzow, Poland
| | - Mariola Woszczyk
- Division of Pediatric Hematology and Oncology, Chorzow Pediatric and Oncology Center, Chorzow, Poland
| | - Renata Tomaszewska
- Department of Pediatric Hematology and Oncology, Silesian Medical University, Zabrze, Poland
| | - Tomasz Szczepański
- Department of Pediatric Hematology and Oncology, Silesian Medical University, Zabrze, Poland
| | - Nina Irga-Jaworska
- Department of Pediatrics, Hematology and Oncology, Medical University, Gdansk, Poland
| | - Elżbieta Drożyńska
- Department of Pediatrics, Hematology and Oncology, Medical University, Gdansk, Poland
| | | | - Grażyna Karolczyk
- Division of Pediatric Hematology and Oncology, Children Hospital, Kielce, Poland
| | - Marcin Płonowski
- Department of Pediatric Oncology and Hematology, Medical University, Bialystok, Poland
| | - Maryna Krawczuk-Rybak
- Department of Pediatric Oncology and Hematology, Medical University, Bialystok, Poland
| | - Jowita Frączkiewicz
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Poland
| | - Malgorzata Salamonowicz
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Poland
| | - Alicja Chybicka
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Poland
| | - Weronika Stolpa
- Division of Pediatric Oncology, Hematology and Chemotherapy, Department of Pediatrics, Silesian Medical University, Katowice, Poland
| | - Grazyna Sobol-Milejska
- Division of Pediatric Oncology, Hematology and Chemotherapy, Department of Pediatrics, Silesian Medical University, Katowice, Poland
| | - Liliana Chełmecka-Wiktorczyk
- Department of Pediatric Oncology and Hematology, University Children's Hospital, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - Walentyna Balwierz
- Department of Pediatric Oncology and Hematology, University Children's Hospital, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - Iwona Zak
- Department of Microbiology, University Children's Hospital, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | | | - Aneta Gietka
- Department of Oncology, Children's Memorial Health Institute, Warszawa, Poland
| | | | - Katarzyna Semczuk
- Department of Microbiology, Children's Memorial Health Institute, Warszawa, Poland
| | | | - Jakub Musiał
- Department of Pediatric Oncohematology, Children Hospital, Rzeszow, Poland
| | - Radoslaw Chaber
- Department of Pediatric Oncohematology, Children Hospital, Rzeszow, Poland
| | - Jerzy Kowalczyk
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, Medical University, Lublin, Poland
| | - Jan Styczyński
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| |
Collapse
|
19
|
Girmenia C, Candoni A, Delia M, Latagliata R, Molteni A, Oliva EN, Palumbo GA, Poloni A, Salutari P, Santini V, Voso MT, Musto P. Infection control in patients with myelodysplastic syndromes who are candidates for active treatment: Expert panel consensus-based recommendations. Blood Rev 2018; 34:16-25. [PMID: 30448050 DOI: 10.1016/j.blre.2018.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/05/2018] [Accepted: 10/26/2018] [Indexed: 12/15/2022]
Abstract
The improvement in supportive care and the introduction of new therapeutic agents, including lenalidomide and hypomethylating agents, in myelodysplastic syndromes have improved patients' outcomes; however, at the same time, the frequency and epidemiology of infections have changed. Therefore, the great strides in the indications and use of new treatment strategies for myelodysplastic syndromes need a parallel progress in the best approach to prophylaxis and supportive therapy for infections. Based on the recognition that the above issues represent an unmet clinical need in myelodysplastic syndromes, an Italian expert panel performed a review of the literature and composed a framework of the best recommendations for optimal infection control in patient candidates to receive active treatment for myelodysplastic syndromes. In this consensus document we report the outcomes of that review and of the consensus meetings held during 2017. The issues tackled in the project dealt with: information to be collected from candidates for active treatment for myelodysplastic syndromes; how to monitor the risk of infection; antimicrobial prophylaxis; the role of iron chelation and antiviral/antibacterial vaccinations. For each of these issues, practice recommendations are provided.
Collapse
Affiliation(s)
- Corrado Girmenia
- Dipartimento di Ematologia, Oncologia e Dermatologia, Policlinico Umberto I, Sapienza University of Rome, Italy.
| | - Anna Candoni
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Mario Delia
- Hematology and BMT Unit, Policlinic of Bari, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Roberto Latagliata
- Dipartimento di Ematologia, Oncologia e Dermatologia, Policlinico Umberto I, Sapienza University of Rome, Italy
| | | | - Esther N Oliva
- Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | - Giuseppe A Palumbo
- Dipartimento di Scienze Mediche Chirurgiche e Tecnologie Avanzate "G.F.Ingrassia", Università degli Studi di Catania, Catania, Italy
| | - Antonella Poloni
- Clinica di Ematologia, AOU Ospedali Riuniti, Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, Ancona, Italy
| | - Prassede Salutari
- Dipartimento di Ematologia, Medicina Trasfusionale e Biotecnologie, Ospedale Spirito Santo, Pescara, Italy
| | - Valeria Santini
- MDS UNIT, Hematology, AOU-Careggi University Hospital, Department of Experimental and Clinical Medicine, Università degli Studi di Firenze, Florence, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Pellegrino Musto
- Scientific Direction, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, PZ, Italy
| |
Collapse
|
20
|
Infections in Myelodysplastic Syndrome in Relation to Stage and Therapy. Mediterr J Hematol Infect Dis 2018; 10:e2018039. [PMID: 30002795 PMCID: PMC6039080 DOI: 10.4084/mjhid.2018.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 11/30/2022] Open
Abstract
Infections remain a significant problem in myelodysplastic syndromes (MDS) in treated as well in non-treated patients and assume a particular complexity. The susceptibility to infections is due, in the absence of intensive chemotherapies, mainly to functional defects in the myeloid lineage with or without neutropenia. Furthermore, MDS includes a heterogeneous group of patients with very different prognosis, therapy and risk factors regarding survival and infections. You should distinguish risk factors related to the disease, like as neutrophils function impairment, neutropenia, unfavorable cytogenetics and bone marrow insufficiency; factors related to the patient, like as age and comorbidities, and factors related to the therapy. When the patients with MDS are submitted to intensive chemotherapy with and without hematopoietic stem cell transplantation (HSCT), they have a risk factor for infection very similar to that of patients with acute myeloid leukemia (AML), and mostly related to neutropenia. Patients with MDS treated with supportive therapy only or with demethylating agent or lenalidomide or immunosuppressive drugs should have a tailored approach. Most of the infections in MDS originate from bacteria, and the main risk factors are represented by neutropenia, thrombocytopenia, and unfavorable cytogenetics. Thus, it is reasonable to give antibacterial prophylaxis to patients who start the therapy with demethylating agents with a number of neutrophils <500 × 109/L, or with thrombocytopenia and unfavorable cytogenetics. The antifungal prophylaxis is not considered cost/benefit adequate and should be taken into consideration only when there is an antecedent fungal infection or presence of filamentous fungi in the surveillance cultures. Subjects submitted to immunosuppression with ATG+CSA have a high rate of infections, and when severely neutropenic should ideally be nursed in isolation, should be given prophylactic antibiotics and antifungals, regular mouth care including an antiseptic mouthwash.
Collapse
|
21
|
Livio P, Alessandro B, Anna C, Marianna C, Matteo GDP, Luana F, Federica L, Francesco M, Maria TV. Risk of infection in elderly patients with AML and MDS treated with hypomethylating agents. ACTA BIO MEDICA : ATENEI PARMENSIS 2018; 89. [PMCID: PMC6502134 DOI: 10.23750/abm.v89i11-s.7988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/06/2022]
Abstract
The aim of this small volume is to raise awareness among Italian hematologists using hypomethylating drugs about risk - and even more important about “risk management” - and the treatment of the infectious events that may arise during therapy with these drugs. Since we wanted this review to be an extremely practical tool, we have included the most recent clinical case studies, the indications provided by the guidelines and expert opinions. Infectious complications are among the most common adverse events that can arise during treatment with hypomethylating drugs. For this reason, a large portion of the chapters of this small volume has been dedicated to a detailed description (on the basis of an attentive review of the literature) of what the hematologist can expect to encounter in terms of risk of infection, in patients treated with azacitidine or decitabine, and to the preventive investigations to carry out and the active prophylaxis measures recommended before commencing treatment with these drugs. What led us to write this book was the conviction that the critical sharing of the studies published in literature and of our personal experiences could contribute to prompting reflection on how we operate and that this, in turn, would lead to the best possible management of these treatments, both in patients with myelodysplasia and in patients with acute myeloid leukemia, preventing - and efficiently managing - infectious events - during therapy. We should not be misled by the fact that the treatments are prevalently administered on an outpatient basis; these patients due to their disease and, in particular, to their age, are extremely frail, and infectious and hemorrhagic complications are the main causes of their admissions to hospital. But expert knowledge and management of the risks of infection can guarantee better management of their needs on an outpatient basis, with undeniable advantages for the clinic but, first and foremost, for the patients. (www.actabiomedica.it)
Collapse
Affiliation(s)
- Pagano Livio
- Associate Professor of Hematology, Director UOSA “Geriatric Hematology and Rare Blood Disorders” - Department of Radiological, Radiotherapeutic and Hematological Sciences - Foundation Polyclinic University A. Gemelli - IRCCS - Catholic University of the Sacred Heart - Rome,Correspondence: Prof. Livio Pagano Department of Radiological, Radiotherapeutic and Hematological Sciences Foundation Polyclinic A. Gemelli - IRCCS Università Cattolica del Sacro Cuore, Roma E-mail:
| | - Busca Alessandro
- Department of Oncology, SSD Allogeneic Stem Cell Transplant Unit, AOU City of Health and Science University Hub, Turin
| | - Candoni Anna
- Clinical Hematology Unit, Health Authorities-University Hospital of Udine (ASUIUD)
| | - Criscuolo Marianna
- Department of Radiological Radiotherapeutic and Hematological Sciences, Foundation Polyclinic University A. Gemelli, IRCCS, Rome
| | | | - Fianchi Luana
- Department of Radiological, Radiotherapeutic and Hematological Sciences - Foundation Polyclinic University A. Gemelli, IRCCS, Rome
| | - Lessi Federica
- Division of Hematology and Clinical Immunology, Padua University Hospital
| | - Marchesi Francesco
- UOSD Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome
| | - Teresa Voso Maria
- Associate Professor of Hematology, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome
| |
Collapse
|
22
|
Ali AM, Weisel D, Gao F, Uy GL, Cashen AF, Jacoby MA, Wartman LD, Ghobadi A, Pusic I, Romee R, Fehniger TA, Stockerl‐Goldstein KE, Vij R, Oh ST, Abboud CN, Schroeder MA, Westervelt P, DiPersio JF, Welch JS. Patterns of infectious complications in acute myeloid leukemia and myelodysplastic syndromes patients treated with 10-day decitabine regimen. Cancer Med 2017; 6:2814-2821. [PMID: 29058375 PMCID: PMC5727246 DOI: 10.1002/cam4.1231] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/18/2017] [Accepted: 09/23/2017] [Indexed: 12/22/2022] Open
Abstract
Decitabine has been explored as a reduced-intensity therapy for older or unfit patients with acute myeloid leukemia (AML). To better understand the risk of infections during decitabine treatment, we retrospectively examined the culture results from each infection-related serious adverse event that occurred among 85 AML and myelodysplastic syndromes (MDS) patients treated in a prospective clinical study using 10-day cycles of decitabine at Washington University School of Medicine. Culture results were available for 163 infection-related complications that occurred in 70 patients: 90 (55.2%) events were culture-negative, 32 (19.6%) were gram-positive bacteria, 20 (12.3%) were gram-negative bacteria, 12 (7.4%) were mixed, 6 (3.7%) were viral, 2 (1.2%) were fungal, and 1 (0.6%) was mycobacterial. Infection-related mortality occurred in 3/24 (13%) of gram-negative events, and 0/51 gram-positive events. On average, nearly one third of patients experienced an infection-related complication with each cycle, and the incidence did not decrease during later cycles. In summary, in patients receiving 10-day decitabine, infectious complications are common and may occur during any cycle of therapy. Although febrile events are commonly culture-negative, gram-positive infections are the most frequent source of culture-positive infections, but gram-negative infections represent a significant risk of mortality in AML and MDS patients treated with decitabine.
Collapse
Affiliation(s)
- Alaa M. Ali
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Daniel Weisel
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Feng Gao
- Division of Public Health SciencesDepartment of SurgeryWashington UniversitySt. LouisMissouri
| | - Geoffrey L. Uy
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Amanda F. Cashen
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Meagan A. Jacoby
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Lukas D. Wartman
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Armin Ghobadi
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Iskra Pusic
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Rizwan Romee
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Todd A. Fehniger
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | | | - Ravi Vij
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Stephen T. Oh
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Camille N. Abboud
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Mark A. Schroeder
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - Peter Westervelt
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - John F. DiPersio
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| | - John S. Welch
- Department of Internal MedicineDivision of OncologyWashington UniversitySaint LouisMissouri
| |
Collapse
|