Infectious complications in adults undergoing intensive chemotherapy for acute myeloid leukemia in 2001-2005 using the Japan Adult Leukemia Study Group AML201 protocols

Toxicity and outcome of adults with acute myeloid leukemia receiving consolidation with high-dose cytarabine

INTRODUCTION

High-dose cytarabine is considered standard of care as consolidation chemotherapy in adults with acute myeloid leukemia (AML) who are not eligible for allogeneic hematopoietic cell transplantation, but may be associated with significant toxicity. We evaluated the toxicity associated with high-dose cytarabine given as consolidation in AML patients treated at a Brazilian public hospital.

METHODS

We retrospectively reviewed the charts of all patients with AML treated between 2008 and 2020 who obtained complete remission (CR) after one cycle of induction chemotherapy and received consolidation with at least one cycle of high-dose cytarabine (defined as 3 g/m2 every 12 h days 1, 3 and 5).

RESULTS

Among 61 patients who received induction remission, 32 obtained CR and 28 received at least one cycle of high-dose cytarabine, for a total of 67 cycles (median 2 cycles per patient, range 1 - 4). In 45 cycles (67.2%) the patient was discharged after the end of chemotherapy, with a median of 6 days at home (range 3 - 8). Readmission occurred in 31 of the 45 cycles (68.9%). The most frequent toxicities were febrile neutropenia (56.7%), nausea and vomiting (23.9%), oral mucositis (14.9%) and diarrhea (11.9%). Bacteremia was documented in 13 cycles (34.2%). There were three cases of typhlitis and two of invasive fungal disease (aspergillosis and candidemia). Four patients died (14.3%), with two deaths considered treatment-related (candidemia and typhlitis).

CONCLUSION

In the setting of a Brazilian public hospital, high-dose cytarabine as consolidation therapy is feasible, with manageable toxicity profile.

Novel biomarkers to identify complicated course of febrile neutropenia in hematological patients receiving intensive chemotherapy

Febrile neutropenia (FN) is a common consequence of intensive chemotherapy in hematological patients. More than 90% of the patients with acute myeloid leukemia (AML) develop FN, and 5%-10% of them die from subsequent sepsis. FN is very common also in autologous stem cell transplant recipients, but the risk of death is lower than in AML patients. In this review, we discuss biomarkers that have been evaluated for diagnostic and prognostic purposes in hematological patients with FN. In general, novel biomarkers have provided little benefit over traditional inflammatory biomarkers, such as C-reactive protein and procalcitonin. The utility of most biomarkers in hematological patients with FN has been evaluated in only a few small studies. Although some of them appear promising, much more data is needed before they can be implemented in the clinical evaluation of FN patients. Currently, close patient follow-up is key to detect complicated course of FN and the need for further interventions such as intensive care unit admission. Scoring systems such as q-SOFA (Quick Sequential Organ Failure Assessment) or NEWS (National Early Warning Sign) combined with traditional and/or novel biomarkers may provide added value in the clinical evaluation of FN patients.

Infectious complications of induction treatment for acute myeloid leukaemia using the "7 + 3" protocol without antibiotic prophylaxis - 15 years of experience of one clinical site

BACKGROUND

Infectious complications during induction chemotherapy of acute myeloid leukaemia are very common. Prophylactic use of antibiotics however is an ongoing challenge in this situation due to bacterial multi-drug resistance. The aim of this study was to provide a comprehensive overview of the incidence of infectious complications in patients with AML undergoing induction therapy using the "7+3" protocol without routine antibiotic prophylaxis at one clinical site providing specialised haematological care in the Czech Republic, over a period of 15 years. The study also evaluates the aetiological spectrum of causative agents and the development of antibiotic resistance in the context of the use of the various classes of antibiotics. The analysis includes evaluation of the importance of risk factors for infectious complications and their impact on treatment of the underlying disease. The data are compared with published figures for similar cohorts of patients.

PATIENTS AND METHODS

This study presents a retrospective analysis of infectious complications in 242 patients with acute myeloid leukaemia undergoing the first cycle of induction therapy without routine antibiotic prophylaxis in one clinical site in Czech Republic during years 2006-2020.

RESULTS

A total of 363 febrile episodes (FE) were recorded. At least 1 FE during the induction was detected in 229 (94.6%) patients. Clinically defined infection was the cause in 96 (26.4%) FEs and blood stream infection in 69 (19.0%) FEs. Both complications occurred simultaneously in 29 (8.0%) FEs. 169 (46.6%) FEs were evaluated as fever of unknown origin (FUO). The achievement of complete remission had a significant effect on the duration of the FE (6 vs. 9 days, P=0.0005) and on the overall survival duration (79.3 vs. 6.5 months, P<0.0001). Patients diagnosed with infection or FUO at diagnosis were significantly more likely to suffer from colonisation by multi-drug resistant bacterial strains at discharge (29.2% vs. 16.3%, P=0.022). This group of patients used antibiotic therapy for a significantly longer time (35 vs. 23 days, P<0.0001). Infection was a contributing cause of death in 18 (7.4%) patients. Mortality was significantly related to the failure to achieve complete remission (P<0.0001).

CONCLUSION

Infectious mortality during induction treatment without routine antibiotic prophylaxis was comparable to the published cohorts with prophylaxis. Regular microbiology surveillance with adequate initial antibiotic treatment can compensate routine antibiotic prophylaxis with slower development of antibiotic resistance.

Microbiology and prognostic prediction model of bloodstream infection in patients with hematological malignancies

Background

In recent years, with the continuous development of treatments for hematological malignancies (HMs), the remission and survival rates of patients with HMs have been significantly improved. However, because of severe immunosuppression and long-term recurrent neutropenia during treatment, the incidence and mortality of bloodstream infection (BSI) were all high in patients with HMs. Therefore, we analyzed pathogens' distribution and drug-resistance patterns and developed a nomogram for predicting 30-day mortality in patients with BSIs among HMs.

Methods

In this retrospective study, 362 patients with positive blood cultures in HMs were included from June 2015 to June 2020 at West China Hospital of Sichuan University. They were randomly divided into the training cohort (n = 253) and the validation cohort (n = 109) by 7:3. A nomogram for predicting 30-day mortality after BSIs in patients with HMs was established based on the results of univariate and multivariate logistic regression. C-index, calibration plots, and decision curve analysis were used to evaluate the nomogram.

Results

Among 362 patients with BSIs in HMs, the most common HM was acute myeloid leukemia (48.1%), and the most common pathogen of BSI was gram-negative bacteria (70.4%). The final nomogram included the septic shock, relapsed/refractory HM, albumin <30g/l, platelets <30×10⁹/l before BSI, and inappropriate empiric antibiotic treatment. In the training and validation cohorts, the C-indexes (0.870 and 0.825) and the calibration plots indicated that the nomogram had a good performance. The decision curves in both cohorts showed that the nomogram model for predicting 30-day mortality after BSI was more beneficial than all patients with BSIs or none with BSIs.

Conclusion

In our study, gram-negative bacterial BSIs were predominant in patients with HMs. We developed and validated a nomogram with good predictive ability to help clinicians evaluate the prognosis of patients.

A real-world study of infectious complications of venetoclax combined with decitabine or azacitidine in adult acute myeloid leukemia

PURPOSE

The purpose of this study was to identify the incidence, sites and main pathogens, and risk factors for infectious complications occurring in patients with adult acute myeloid leukemia (AML) during the first course of venetoclax combined with decitabine or azacitidine.

METHODS

A retrospective cohort analysis was performed of 81 patients with AML older than 14 years who received the first cycle of venetoclax combined with a hypomethylating agent (HMA) between March 2018 and March 2021 at our institution. Infectious complications, if any, were documented.

RESULTS

Among a total of 81 cases of AML, 59 (72.8%) patients occurred infections, including fever without an identifiable source (28.8%), clinically documented infections (40.7%), and microbiologically documented infections (30.5%). The most commonly isolated organism in culture was Candida albicans, followed by Klebsiella pneumonia, and Pseudomonas aeruginosa. The 4-week and 8-week mortality rates were 3.7% and 7.4%, respectively. In multivariate analysis, a high proportion of blasts in bone marrow, decreased hemoglobin level, and fever with or without a documented infection at baseline were significant independent risk factors for infectious complications.

CONCLUSION

Compared with conventional chemotherapy, the incidence of infectious complications of venetoclax combined with decitabine or azacitidine significantly decreased. Pretreatment high leukemia burden and fever were independent risk factors for infections.

Difference of compliance rates for the recommendations in Japanese Guideline on Febrile Neutropenia according to respondents’ attributes: the second report on a questionnaire survey among hematology-oncology physicians and surgeons

Purpose

The Japanese Society of Medical Oncology (JSMO) published a guideline (GL) on febrile neutropenia (FN) in 2017. This study aims to identify promoting factors and disincentives for complying with GL recommendations according to attributes of doctors providing chemotherapy.

Methods

A questionnaire survey was conducted with SurveyMonkey™ for physician members of the Japanese Association of Supportive Care in Cancer and relevant academic organizations. Each question had four options (always do, do in more than half of patients, do in less than half, do not at all) and a free description form. Responses were analyzed according to the respondents’ attributes.

Result

Seven hundred eighty-eight out of retrieved 801 responses were available for analysis. Multivariable analysis demonstrated that the percentage of GL users was higher among women and Japanese Society of Clinical Oncology members. The overall compliance rate was higher among women, JSMO members, and board-certified medical oncologists. Internists emphasized the significance of collecting blood cultures at FN onset, and surgeons stressed the importance of G-CSF prophylaxis. Hematologists were less likely to adhere to recommendations on risk assessment of FN by the Multinational Association of Supportive Care in Cancer score and administration of gammaglobulin products. However, those are acceptable due to the characteristics of their practice. Eight recommendations had no difference in compliance rates between users and non-users, some of whose statements were ambiguous and discretionary.

Conclusion

Women were more likely to use and adhere to GL. The recommendations should be developed considering the characteristics of specialty and subspecialty and avoiding ambiguity and discretionary statements.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-06834-9.

Predictive and risk factor analysis for bloodstream infection in high-risk hematological patients with febrile neutropenia: post-hoc analysis from a prospective, large-scale clinical study

OBJECTIVES

Bloodstream infection (BSI) is a frequent complication observed in patients with febrile neutropenia (FN). BSI risk factors and incidence vary depending on chemotherapy types and prophylactic antimicrobial agents. We clarified these issues by post-hoc analysis of a prospective clinical trial cohort for severe FN in hematological malignancy.

METHODS

We performed an intention-to-treat analysis of 413 high-risk patients and 1272 blood culture sets.

RESULTS

Overall, 356 patients (86.2%) developed FN, and 20.8% had BSI complications. Prophylactic antimicrobials did not prevent complications of FN and BSI, but the incidence of BSIs of Gram-negative (GN) bacteria was lower than in the non-prophylaxis group (23.8% vs. 56.7%). Multinational Association of Supportive Care in Cancer (MASCC) scores < 20 were significantly correlated with the incidence of BSI, whereas MASCC scores > 21 were not (41.7% vs. 17.2%). The only significant risk factors were hypotension and dehydration. axillary temperatures were higher in GN-caused BSIs than in Gram-positive-caused BSIs and in patients with negative blood culture results (38.7 °C vs. 38.2 °C vs. 38.0 °C). The higher the fever, the higher the incidence of BSI and GN bacteremia.

CONCLUSIONS

MASCC score and axillary temperature are strong predictors of BSI. Non-administration of prophylactic antimicrobials and GN-caused BSI are correlated.

THE CLINICAL TRIAL REGISTRATION NUMBER

UMIN00010411.

Efficacy and safety of chemotherapy combined with different doses of IL-2 maintenance therapies for acute myeloid leukemia: A protocol for a Bayesian network meta-analysis

BACKGROUND

Acute myeloid leukemia (AML) is the most common malignant tumor of the hematopoietic system, which seriously threatens the lives of patients. Most AML patients have acute onset, severe condition, and poor prognosis. The present study aimed to comprehensively evaluate the effectiveness and safety of chemotherapy combined with different doses of interleukin-2 (IL-2) maintenance treatments in AML by Bayesian network meta-analysis (NMA).

METHODS

From its inception until October 2021, we will search PubMed, Cochrane Library, CNKI, Embase, and other databases to comprehensively collect randomized controlled trials (RCTs) of chemotherapy combined with different doses of IL-2 maintenance therapies for AML. Two independent researchers will complete the literature screening and data extraction according to the inclusion and exclusion criteria, and then independently conduct a bias risk assessment of all the evidence. Bayesian NMA was used to evaluate all the evidence comprehensively. Use STATA16.0 and WinBUGS1.4.3 software to process and analyze all data, and classify the quality of evidence in NMA according to grading of recommendations assessment, development, and evaluation .

RESULTS

The study will evaluate the efficacy and safety of chemotherapy combined with different doses of IL-2 maintenance therapies for AML.

CONCLUSION

The study will provide a basis for the efficacy and safety of chemotherapy combined with different doses of IL-2 maintenance therapies for AML. We hope that this study can provide meaningful support for clinicians and patients.

PROTOCOL REGISTRATION NUMBER

INPLASY202140106.

ETHICAL APPROVAL

Since the study is based on published or registered RCTs, ethical approval and patient informed consent are abandoned.

Medicinal Plants with Anti-Leukemic Effects: A Review

Leukemia is a leukocyte cancer that is characterized by anarchic growth of immature immune cells in the bone marrow, blood and spleen. There are many forms of leukemia, and the best course of therapy and the chance of a patient’s survival depend on the type of leukemic disease. Different forms of drugs have been used to treat leukemia. Due to the adverse effects associated with such therapies and drug resistance, the search for safer and more effective drugs remains one of the most challenging areas of research. Thus, new therapeutic approaches are important to improving outcomes. Almost half of the drugs utilized nowadays in treating cancer are from natural products and their derivatives. Medicinal plants have proven to be an effective natural source of anti-leukemic drugs. The cytotoxicity and the mechanisms underlying the toxicity of these plants to leukemic cells and their isolated compounds were investigated. Effort has been made throughout this comprehensive review to highlight the recent developments and milestones achieved in leukemia therapies using plant-derived compounds and the crude extracts from various medicinal plants. Furthermore, the mechanisms of action of these plants are discussed.

Febrile neutropenia in patients with acute myeloid leukemia: Outcome in relation to qSOFA score, C-reactive protein, and blood culture findings

OBJECTIVES

To evaluate quick Sequential Organ Failure Assessment (qSOFA) score during febrile neutropenia (FN) in adult patients receiving intensive chemotherapy for acute myeloid leukemia (AML).

METHODS

qSOFA score, as well as the association of qSOFA score with ICU admission, infectious mortality, blood culture findings, and C-reactive protein (CRP) measurements during FN were assessed among 125 adult AML patients with 355 FN periods receiving intensive chemotherapy in a tertiary care hospital from November 2006 to December 2018.

RESULTS

The multivariate model for qSOFA score ≥ 2 included CRP ≥ 150 mg/L on d0-2 [OR 2.9 (95% CI 1.1-7.3), P = .026], Gram-negative bacteremia [OR 2.7 (95% CI 1.1-6.9), P = .034], and treatment according to AML-2003 vs more recent protocols [OR 2.7 (95% CI 1.0-7.4), P = .047]. Age or gender did not gain significance in the model. qSOFA score ≥ 2 was associated with ICU treatment and infectious mortality during FN with sensitivity and specificity of 0.700 and 0.979, and 1.000 and 0.971, respectively.

CONCLUSION

qSOFA offers a useful tool to evaluate the risk of serious complications in AML patients during FN.

Infection profiles of different chemotherapy regimens and the clinical feasibility of antimicrobial prophylaxis in patients with DLBCL

Various chemotherapy regimens are used to treat patients with diffuse large B-cell lymphoma (DLBCL). However, treatment-related toxicity with a focus on infectious disease has not been fully reviewed. Several phase 3 trials have demonstrated different rates of febrile neutropenia (FN) between regimens (e.g. dose-adjusted (DA) EPOCH-R vs. R-CHOP). With heterogeneous patient characteristics, a combination regimen of lenalidomide or ibrutinib with R-CHOP exhibited promising efficacy with moderate infectious toxicity. While R-bendamustine is feasible for patients who don't tolerate other forms of chemotherapy, clinical data indicate increased opportunistic infections under prolonged lymphopenia. The usefulness of prophylactic antibiotics/antifungal agents in DLBCL patients is controversial owing to shorter and less severe neutropenia than with the induction regimen for acute leukemia or hematopoietic stem-cell transplantation. Prophylactic granulocyte-colony stimulating factor is recommended for intensive regimens such as DA-EPOCH-R, R-DHAP, or R-ICE. Regardless of multiple studies about FN incidence, studies focusing on microbiologic events are limited, and further investigations are warranted.

Early detection of infectious complications during induction therapy for acute leukemia with serial C-reactive protein biomarker assessment

Febrile neutropenia (FN) and blood stream infections (BSI) are major complications of induction treatment for acute leukemia. We assessed the predictive utility of C-reactive protein (CRP), an acute phase reactant, for FN and BSI during induction. CRP levels and dynamics were analyzed in 138 consecutive patients. FN and BSI occurred in 110 (80.3%) and 10 (7.5%) patients, respectively. Median peak CRP level in the 24-hours preceding FN was 7.5 mg/dl (0.2-38.1) vs. median peak CRP level of 5.11 mg/dl (0.2-23.1, p = .009) in patients without FN. CRP levels preceding BSI were 13.1 mg/dl (6.9-27.9) vs. 6.3 mg/dl (0.16-38.14, p = .011). CRP increase prior to event (ΔCRP) was higher among patients with BSI vs. patients without BSI (p = .013). CRP was predictive for FN (p = .009) and BSI (p = .01) on ROC curve analysis and was also independently associated with FN on multivariate analysis. In conclusion, CRP is a sensitive biomarker that precedes FN and BSI.

Percutaneous coronary intervention and in-hospital outcomes in patients with leukemia: a nationwide analysis

OBJECTIVES

To examine the association between current leukemia diagnosis and in-hospital clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) in the United States.

BACKGROUND

Leukemia is the most common hematological malignancy and is associated with an increased risk of thrombotic and bleeding complications in patients undergoing PCI. There are limited data around clinical outcomes of leukemia patients undergoing PCI.

METHODS

We used the National Inpatient Sample to investigate the outcomes of leukemia patients undergoing PCI between 2004 and 2014. Patients were then subdivided into diagnoses of acute myeloid leukemia (AML) or chronic myeloid leukemia and acute lymphoid leukemia or chronic lymphoid leukemia (CLL). Multiple logistic regressions were used to study the association of a leukemia diagnosis with in-hospital outcomes: mortality, bleeding, vascular and cardiac complications, and stroke.

RESULTS

There were 6,561,445 records of patients who underwent PCI during the study time, of which 15,789 patients had a diagnosis of leukemia. The most common leukemia subtype was CLL accounting for 75% of the cohort (n = 10,800). After multivariable adjustment, a leukemia diagnosis was associated with significantly increased odds of in-hospital mortality (odds ratio [OR]: 1.41; 95% confidence interval [CI]: [1.11-1.79]) and bleeding (OR: 1.87; 95% CI: [1.56-2.09]), whereas patients with AML had a fivefold increase of in-hospital mortality (OR: 5.38; 95% CI: [2.94-9.76]).

CONCLUSIONS

Patients with current diagnosis of leukemia are at increased risk of procedure-related complications following PCI. A multidisciplinary approach is needed among interventional cardiologists, oncologists, and hematologists to minimize procedural complications and improve outcomes in this high-risk cohort.

Efficacy of levofloxacin as an antibacterial prophylaxis for acute leukemia patients receiving intensive chemotherapy: a systematic review and meta-analysis

OBJECTIVES

The incidence of febrile neutropenia (FN) in acute leukemia patients following induction or consolidation chemotherapy is high. Several clinical practice guidelines recommend the use of a fluoroquinolone prophylaxis to prevent bacterial infection in patients being prone to prolonged profound neutropenia.

METHODS

This systematic review and meta-analysis aimed to investigate the efficacy and complications of levofloxacin as a prophylaxis for FN patients following chemotherapy for acute leukemia. Two databases from MEDLINE and EMBASE were searched for published studies indexed before 10 July 2018.

RESULTS

A total of 862 acute leukemia patients were included, with 356 in the levofloxacin prophylaxis arm and 506 in the no-prophylaxis arm. Patients receiving levofloxacin had a significantly lower FN rate than patients who did not receive the antibiotic prophylaxis (odds ratio [OR]: 0.43, 95% confidence interval [CI]: 0.32-0.58, p < .00001, I² = 0%). The rate of microbiologically documented infection in the no-prophylaxis group was higher than that for the levofloxacin prophylaxis group (OR: 0.45, 95% CI: 0.34-0.60, p < .00001, I² = 0%). The bacteremia rate in the levofloxacin prophylaxis group was significantly lower than that for the no-prophylaxis group (OR: 0.45, 95% CI: 0.31-0.66, p < .00001, I² = 0%). However, the mortality rates of the two groups were quite similar between the two groups (OR: 0.67, 95% CI: 0.34-1.33, p = .26, I² = 0%).

CONCLUSIONS

Although the levofloxacin prophylaxis for the acute leukemia patients receiving intensive chemotherapy showed advantages for infectious complications, it did not affect mortality.