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Mądry K, Lis K, Sienkiewicz E, Drozd-Sokołowska J, Biecek P, Sośnia O, Gołos A, Olszewska-Szopa M, Obara A, Walkowiak Z, Ściesińska J, Subocz E, Butrym A, Machowicz R, Budziszewska K, Basak G. No advantage of antimicrobial prophylaxis in AML/MDS/CMML patients treated with azacitidine-a prospective multicenter study by the Polish Adult Leukemia Group. Front Oncol 2024; 14:1404322. [PMID: 38939343 PMCID: PMC11208299 DOI: 10.3389/fonc.2024.1404322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/26/2024] [Indexed: 06/29/2024] Open
Abstract
Introduction Infections represent one of the most frequent causes of death of higher-risk MDS patients, as reported previously also by our group. Azacitidine Infection Risk Model (AIR), based on red blood cell (RBC) transfusion dependency, neutropenia <0.8 × 109/L, platelet count <50 × 109/L, albumin <35g/L, and ECOG performance status ≥2 has been proposed based on the retrospective data to estimate the risk of infection in azacitidine treated patients. Methods The prospective non-intervention study aimed to identify factors predisposing to infection, validate the AIR score, and assess the impact of antimicrobial prophylaxis on the outcome of azacitidine-treated MDS/AML and CMML patients. Results We collected data on 307 patients, 57.6 % males, treated with azacitidine: AML (37.8%), MDS (55.0%), and CMML (7.1%). The median age at azacitidine treatment commencement was 71 (range, 18-95) years. 200 (65%) patients were assigned to higher risk AIR group. Antibacterial, antifungal, and antiviral prophylaxis was used in 66.0%, 29.3%, and 25.7% of patients, respectively. In total, 169 infectious episodes (IE) were recorded in 118 (38.4%) patients within the first three azacitidine cycles. In a multivariate analysis ECOG status, RBC transfusion dependency, IPSS-R score, and CRP concentration were statistically significant for infection development (p < 0.05). The occurrence of infection within the first three azacitidine cycles was significantly higher in the higher risk AIR group - 47.0% than in lower risk 22.4% (odds ratio (OR) 3.06; 95% CI 1.82-5.30, p < 0.05). Administration of antimicrobial prophylaxis did not have a significant impact on all-infection occurrence in multivariate analysis: antibacterial prophylaxis (OR 0.93; 0.41-2.05, p = 0.87), antifungal OR 1.24 (0.54-2.85) (p = 0.59), antiviral OR 1.24 (0.53-2.82) (p = 0.60). Discussion The AIR Model effectively discriminates infection-risk patients during azacitidine treatment. Antimicrobial prophylaxis does not decrease the infection rate.
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Affiliation(s)
- Krzysztof Mądry
- Department of Hematology, Transplantation and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Karol Lis
- Department of Hematology, Transplantation and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Elzbieta Sienkiewicz
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warsaw, Poland
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Transplantation and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Biecek
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warsaw, Poland
| | - Oktawia Sośnia
- Department of Hematology, Institute of Hematology and Transfusiology, Warsaw, Poland
| | | | - Magdalena Olszewska-Szopa
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wrocław, Poland
| | - Agata Obara
- Department of Hematology, Holycross Cancer Center, Kielce, Poland
| | - Zuzanna Walkowiak
- Department of Hematology, Multi-Specialist Hospital Gorzów Wielkopolski, Faculty of Medicine and Health Science, University of Zielona Góra, Gorzów Wielkopolski, Poland
| | - Joanna Ściesińska
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdańsk, Poland
| | - Edyta Subocz
- Department of Hematology, Warmian-Masurian Cancer Center of the Ministry of the Interior and Administration’s Hospital, Olsztyn, Poland
| | - Aleksandra Butrym
- Department of Cancer Prevention and Therapy, Wroclaw Medical University, Wrocław, Poland
| | - Rafał Machowicz
- Department of Hematology, Transplantation and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | | | - Grzegorz Basak
- Department of Hematology, Transplantation and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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Majid H, Masoom M, Bansal N, Ahmad W, Khan MF, Farooqui S, Bhurani D, Khan MA. Spectrum of infections in different regimens of post-induction chemotherapy in acute myeloid leukemia ( de-novo): A comparative retrospective study. Heliyon 2024; 10:e24561. [PMID: 38317981 PMCID: PMC10839883 DOI: 10.1016/j.heliyon.2024.e24561] [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: 12/07/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 02/07/2024] Open
Abstract
Background Patients diagnosed with acute myeloid leukemia (AML) face a heightened susceptibility to infections, which significantly elevates their risk of mortality and disability. The intensity of the chemotherapy treatment and its specific focus on inhibiting myeloid cell divisions render patients especially vulnerable, particularly during the early stages of chemotherapy. This vulnerability is compounded by the occurrence of repeated episodes of prolonged neutropenia, leaving patients highly susceptible to infections. The compromised immune systems of these individuals make them more susceptible to infections, which adversely affect their physical health and overall well-being. Consequently, our study aimed to investigate the range of infections experienced by patients with newly diagnosed AML undergoing different induction chemotherapy. Methods This was a comparative retrospective study, conducted at a tertiary hospital providing comprehensive cancer care in North India. All newly diagnosed patients with AML, who received induction chemotherapy from January 1, 2012 to November 1, 2022, were identified from the hospital database and included in this study. Results Four hundred and twenty AML patients treated with either high-intensity or low-intensity induction chemotherapy was observed in this study. It was found that patients who received high-intensity treatment had a higher rate of clinically and microbiologically documented infections, fever without a known cause, and more cases of febrile neutropenia than those who got low-intensity treatment. These differences between the two groups were particularly evident on day 14 (p = 0.0002) and persisted through day 28 (p = 0.005). Conclusions These findings underscore the effectiveness and downside of high-intensity induction chemotherapy regimens, as evidenced by the higher incidence of infections observed. Further investigation through prospective clinical studies is warranted to better evaluate and validate the efficacy of this approach.
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Affiliation(s)
- Haya Majid
- Department of Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Md Masoom
- Department of Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Nitin Bansal
- Department of Haemato-Oncology & Bone Marrow Transplantation, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi, 110085, India
| | - Wasim Ahmad
- Department of Pharmacy, Mohammed Al-Mana College for Medical Sciences, Safaa, Dammam 34222, Saudi Arabia
| | - Mohd Faiyaz Khan
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Sadaf Farooqui
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Dinesh Bhurani
- Department of Haemato-Oncology & Bone Marrow Transplantation, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi, 110085, India
| | - Mohd Ashif Khan
- Department of Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
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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.
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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.
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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
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Wanitpongpun C, Teawtrakul N, Lanamtieng T, Chansung K, Sirijeerachai C, Amampai W, Sawanyawisuth K. Clinical factors predictive of recurrent febrile neutropenia in adult patients with acute leukemia. Leuk Res Rep 2022; 17:100296. [PMID: 35251930 PMCID: PMC8889242 DOI: 10.1016/j.lrr.2022.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 01/27/2022] [Accepted: 02/14/2022] [Indexed: 11/30/2022] Open
Abstract
Febrile neutropenia (FN) is considered an oncologic emergency in acute leukemia. There were 250 FN events in 124 hospitalized patients with hematologic malignancy. These data imply that two FN events may occur per patient, yet data on the prevalence, risk factors, and outcomes of recurrent FN in adult patients with leukemia are limited. A retrospective cohort study was conducted that enrolled adult patients diagnosed with acute leukemia who developed FN. The eligible patients were categorized as with or without recurrent FN. A stepwise, multivariate logistic regression analysis was performed to identify predictors of recurrent FN. A total of 203 patients met the study criteria; of these, 46 (22.66%) had recurrent FN, and this group had a median of three recurrent FN emergencies. After adjusted, three independent factors remained in the final model including ALL, FN at admission, and treatment with idarubicin (3 days) and cytarabine (7 days). The three factors were positively associated with recurrent FN with adjusted odds ratios of 6.253, 4.068, and 10.757, respectively. No significant differences were found between the two groups in terms of other sources of infection, other pathogens, ICU stay, hospital stay, and mortality. ALL and FN at admission and treatment with idarubicin (3 days) and cytarabine (7 days) were associated with recurrent FN in acute leukemia patients with FN. Clinical outcomes for patients with or without recurrent FN were mostly comparable; however, due to its small sample size, further studies are required to confirm the results of this study.
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Mądry K, Lis K, Biecek P, Młynarczyk M, Rytel J, Górka M, Kacprzyk P, Dutka M, Rodzaj M, Bołkun Ł, Krochmalczyk D, Łątka E, Drozd-Sokołowska J, Waszczuk-Gajda A, Knopińska-Posłuszny W, Kopińska A, Subocz E, Masternak A, Guzicka-Kazimierczak R, Gil L, Machowicz R, Biliński J, Giebel S, Czerw T, Dwilewicz-Trojaczek J. Predictive Model for Infection Risk in Myelodysplastic Syndromes, Acute Myeloid Leukemia, and Chronic Myelomonocytic Leukemia Patients Treated With Azacitidine; Azacitidine Infection Risk Model: The Polish Adult Leukemia Group Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:264-274.e4. [PMID: 30898482 DOI: 10.1016/j.clml.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/04/2019] [Accepted: 01/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Myelodysplastic syndromes (MDS), chronic myelomonocytic leukemia (CMML), and acute myeloid leukemia (AML) patients, including those treated with azacitidine, are at increased risk for serious infections. The aim of our study was to identify patients with higher infectious risk at the beginning of azacitidine treatment. PATIENTS AND METHODS We performed a retrospective evaluation of 298 MDS/CMML/AML patients and included in the analysis 232 patients who completed the first 3 cycles of azacitidine therapy or developed Grade III/IV infection before completing the third cycle. RESULTS Overall, 143 patients (62%) experienced serious infection, and in 94 patients (41%) infection occurred within the first 3 cycles. The following variables were found to have the most significant effect on the infectious risk in multivariate analysis: red blood cell transfusion dependency (odds ratio [OR], 2.38; 97.5% confidence interval [CI], 1.21-4.79), neutropenia <0.8 × 109/L (OR, 3.03; 97.5% CI, 1.66-5.55), platelet count <50 × 109/L (OR, 2.63; 97.5% CI, 1.42-4.76), albumin level <35 g/dL (OR, 2.04; 97.5% CI, 1.01-4.16), and Eastern Cooperative Oncology Group performance status ≥2 (OR, 2.19; 97.5% CI, 1.40-3.54). Each of these variables is assigned 1 point, and the combined score represents the proposed Azacitidine Infection Risk Model. The infection rate in the first 3 cycles of therapy in lower-risk (0-2 score) and higher-risk (3-5 score) patients was 25% and 73%, respectively. The overall survival was significantly reduced in higher-risk patients compared with the lower-risk cohort (8 vs. 29 months). CONCLUSION We selected a subset with high early risk for serious infection and worse clinical outcome among patients treated with azacitidine.
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Affiliation(s)
- Krzysztof Mądry
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Karol Lis
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland.
| | - Przemysław Biecek
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warsaw, Poland
| | - Magda Młynarczyk
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warsaw, Poland
| | - Jagoda Rytel
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Michał Górka
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Piotr Kacprzyk
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Magdalena Dutka
- Department of Hematology and Bone Marrow Transplantation, Medical University, Gdańsk, Poland
| | - Marek Rodzaj
- Department of Hematology, Voivodal Specialistic Hospital, Kraków, Poland
| | - Łukasz Bołkun
- Department of Hematology, Medical University, Białystok, Poland
| | | | - Ewa Łątka
- Department of Hematology, Jagiellonian University, Kraków, Poland
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Anna Waszczuk-Gajda
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | | | - Anna Kopińska
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | - Edyta Subocz
- Department of Hematology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Anna Masternak
- Department of Hematology, Specialist Hospital, Opole, Poland
| | | | - Lidia Gil
- Department of Hematology, Medical University, Poznań, Poland
| | - Rafał Machowicz
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Jarosław Biliński
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Hematology-Oncology, Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Tomasz Czerw
- Department of Bone Marrow Transplantation and Hematology-Oncology, Cancer Center and Institute of Oncology, Gliwice, Poland
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Shargian-Alon L, Gurion R, Raanani P, Yahav D, Gafter-Gvili A. Hypomethylating Agents-associated Infections—Systematic Review and Meta-analysis of Randomized Controlled Trials. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:603-610.e1. [DOI: 10.1016/j.clml.2018.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/12/2018] [Accepted: 05/21/2018] [Indexed: 01/24/2023]
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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.
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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.
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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
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Radsak M, Platzbecker U, Schmidt CS, Hofmann WK, Nolte F. Infectious complications in patients with myelodysplastic syndromes: A review of the literature with emphasis on patients treated with 5-azacitidine. Eur J Haematol 2017; 99:112-118. [PMID: 28321924 DOI: 10.1111/ejh.12883] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 01/17/2023]
Abstract
Myelodysplastic Syndromes are oligo-clonal stem cell disorders that are associated with cytopenias in the peripheral blood. Major causes for morbidity and mortality in myelodysplastic syndromes (MDS) patients are infections mostly due to bacteria or fungi. Beside leucopenia per se in affected patients, function of white blood cells particularly that of neutrophils seems to be impaired. Here we summarize the available data on infections in MDS patients in general and particularly those treated with 5-azacitidine.
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Affiliation(s)
- Markus Radsak
- 3rd Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Uwe Platzbecker
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Cornelia S Schmidt
- 3rd Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Wolf-Karsten Hofmann
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Florian Nolte
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
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11
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Trubiano JA, Dickinson M, Thursky KA, Spelman T, Seymour JF, Slavin MA, Worth LJ. Incidence, etiology and timing of infections following azacitidine therapy for myelodysplastic syndromes. Leuk Lymphoma 2017; 58:2379-2386. [PMID: 28278704 DOI: 10.1080/10428194.2017.1295141] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We examine the infective complications occurring during azacitidine (AZA) therapy in patients with myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). A retrospective review of patients receiving ≥1 cycle of AZA for MDS or AML was performed. Patient demographics, infection prophylaxis/episodes and outcomes were evaluated. Sixty eight patients received 884 AZA cycles. Bacterial infections occurred in 25% of cycle-1 and 27% of cycle-2 AZA therapy. Febrile neutropenia complicated 5.3% of AZA cycles, bacteremia 2% and invasive Aspergillosis 0.3%. Using Poisson modeling, a very high IPSS-R (RR 10.26, 95% CI 1.20, 87.41, p= .033) was identified as an independent risk factor for infection. Infection-related attributable mortality was 23%. The burden of infection is high in AZA-treated patients, associated with high attributable mortality. Over 25% of AZA cycles 1 and 2 were complicated by infection, predominantly bacterial, rates dropping to <10% after cycle-5.
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Affiliation(s)
- Jason A Trubiano
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , East Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia
| | - Michael Dickinson
- c Department of Haematology , Peter MacCallum Cancer Centre , East Melbourne , Australia
| | - Karin A Thursky
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , East Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia.,d Victorian Infectious Diseases Service , Royal Melbourne Hospital at the Peter Doherty Institute , Melbourne , Australia
| | - Timothy Spelman
- b Department of Medicine , University of Melbourne , Melbourne , Australia
| | - John F Seymour
- b Department of Medicine , University of Melbourne , Melbourne , Australia.,c Department of Haematology , Peter MacCallum Cancer Centre , East Melbourne , Australia
| | - Monica A Slavin
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , East Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia.,d Victorian Infectious Diseases Service , Royal Melbourne Hospital at the Peter Doherty Institute , Melbourne , Australia
| | - Leon J Worth
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , East Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia
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12
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Jeong SH, Kim YJ, Lee JH, Kim YK, Kim SJ, Park SK, Do YR, Kim I, Mun YC, Kim HG, Lee WS, Yi HG, Joo YD, Choi CW, Kim SR, Na SM, Jang JH. A prospective, multicenter, observational study of long-term decitabine treatment in patients with myelodysplastic syndrome. Oncotarget 2016; 6:44985-94. [PMID: 26517692 PMCID: PMC4792606 DOI: 10.18632/oncotarget.6242] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 09/24/2015] [Indexed: 11/25/2022] Open
Abstract
This prospective observational study evaluated the efficacy and safety of long-term decitabine treatment in patients with myelodysplastic syndrome (MDS). Decitabine 20 mg/m2/day was administered intravenously for 5 consecutive days every 4 weeks to MDS patients in intermediate-1 or higher International Prognostic Scoring System (IPSS) risk categories. Active antimicrobial prophylaxis was given to prevent infectious complications. Overall response rate (ORR), overall survival (OS), progression-free survival (PFS), and time to response were evaluated, as were adverse events. The final analysis included 132 patients. IPSS risk was intermediate-2/high in 34.9% patients. The patients received a median of 5 cycles, with responders receiving a median of 8 cycles (range, 2-30). ORR was 62.9% (complete response [CR], 36; partial response [PR], 3; marrow complete response [mCR], 19; and hematologic improvement, 25). Among responders, 39% showed first response at cycle 3 or later. OS at 2 years was 60.9%, with 17% progressing to acute myeloid leukemia. PFS at 2 years was 51.0%. Patients achieving mCR showed comparable survival outcomes to those with CR/PR. With active antibiotic prophylaxis, febrile neutropenia events occurred in 61 of 1,033 (6%) cycles. Long-term decitabine treatment with antibiotic prophylaxis showed favorable outcomes in MDS patients, and mCR predicted favorable survival outcomes.
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Affiliation(s)
- Seong Hyun Jeong
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon, South Korea
| | - Yoo-Jin Kim
- Department of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Je-Hwan Lee
- Department of Hematology, Asan Medical Center, Seoul, Korea
| | - Yeo-Kyeoung Kim
- Department of Hematology, Chonnam National University Hwasun Hospital, Jeollanam-do, South Korea
| | - Soo Jeong Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kyu Park
- Department of Internal Medicine, Soonchunhyang University Hospital, Bucheon, South Korea
| | - Young Rok Do
- Division of Hematology-Oncology, School of Medicine, Keimyung University, Daegu, South Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University, Seoul, Korea
| | - Yeung-Chul Mun
- Department of Hematology and Oncology, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Hoon Gu Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Gyeongnam Regional Cancer Center, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, South Korea
| | - Won Sik Lee
- Department of Internal Medicine, Inje University College of Medicine, Inje University Busan Paik Hospital, Busan, South Korea
| | - Hyeon Gyu Yi
- Department of Internal Medicine, Inha University College of Medicine, Incheon, South Korea
| | - Young-Don Joo
- Hematology-Oncology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, Busan, South Korea
| | - Chul Won Choi
- Division of Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | | | | | - Jun Ho Jang
- Division of Hematology and Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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13
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Bainschab A, Quehenberger F, Greinix HT, Krause R, Wölfler A, Sill H, Zebisch A. Infections in patients with acute myeloid leukemia treated with low-intensity therapeutic regimens: Risk factors and efficacy of antibiotic prophylaxis. Leuk Res 2016; 42:47-51. [PMID: 26866663 DOI: 10.1016/j.leukres.2016.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 12/16/2022]
Abstract
Survival of acute myeloid leukemia (AML) patients, who are unfit for high-dose chemotherapy, has significantly improved with the advent of low-intensity therapeutic regimens (LITR, comprising decitabine, azacitidine, and low-dose cytarabine). However, infectious complications are common during LITR treatment and might hamper the beneficial effect of these drugs. In this study, we aimed to evaluate the incidence of and predisposing risk factors for infections during LITR treatment of AML, as well as the value of antibiotic prophylaxis within this setting. Therefore, we retrospectively analyzed 40 AML patients, treated with 215 cycles of LITR and analyzed putative risk factors by multivariate logistic regression. Infections occurred in 53/215 (25%) of LITR cycles, resulting in death in six patients. Of the parameters assessed at the start of each LITR cycle, transfusion dependence (p=0.008) and increased LDH (p=0.027) independently predicted the occurrence of infection. Most importantly, however, antibiotic prophylaxis was independently associated with a decreased rate of infectious complications (p=0.030). It was regularly performed in neutropenic patients and even managed to eliminate low neutrophil counts as risk factor in multivariate models. These data argue for the efficacy of antibiotic prophylaxis during LITR therapy of AML and suggest its further evaluation within a prospective clinical trial.
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Affiliation(s)
- Antonia Bainschab
- Division of Hematology, Medical University of Graz, Auenbruggerplatz 38, A-8036 Graz, Austria
| | - Franz Quehenberger
- Institute of Medical Informatics, Statistics and Documentation, Medical University of Graz, Auenbruggerplatz 2, A-8036 Graz, Austria
| | - Hildegard T Greinix
- Division of Hematology, Medical University of Graz, Auenbruggerplatz 38, A-8036 Graz, Austria
| | - Robert Krause
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036 Graz, Austria
| | - Albert Wölfler
- Division of Hematology, Medical University of Graz, Auenbruggerplatz 38, A-8036 Graz, Austria
| | - Heinz Sill
- Division of Hematology, Medical University of Graz, Auenbruggerplatz 38, A-8036 Graz, Austria
| | - Armin Zebisch
- Division of Hematology, Medical University of Graz, Auenbruggerplatz 38, A-8036 Graz, Austria.
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14
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Stamatoullas A, Rezine I, Mareschal S, Ménard AL, Lanic H, David M, Daliphard S, Penther D, Lemasle E, Cassuto O, Lenain P, Contentin N, Lepretre S, Jardin F, Bastard C, Tilly H. Hypoalbuminemia and hypergammaglobulinemia are associated with an increased infection risk in patients with myeloid malignancies treated with azacitidine. A 3-year monocentric retrospective study. Leuk Lymphoma 2015; 57:1491-3. [PMID: 26430832 DOI: 10.3109/10428194.2015.1101096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | | | | | | | - Marion David
- c Biopathology Department , Centre Henri Becquerel , Rouen , France
| | - Sylvie Daliphard
- d Hematology Laboratory , Centre Hospitalier Universitaire , 1 Rue d'Amiens, 76038 Rouen cedex , France
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15
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Abou Zahr A, Saad Aldin E, Barbarotta L, Podoltsev N, Zeidan AM. The clinical use of DNA methyltransferase inhibitors in myelodysplastic syndromes. Expert Rev Anticancer Ther 2015; 15:1019-36. [DOI: 10.1586/14737140.2015.1061936] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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16
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Ofran Y, Filanovsky K, Gafter-Gvili A, Vidal L, Aviv A, Gatt ME, Silbershatz I, Herishanu Y, Arad A, Tadmor T, Dally N, Nemets A, Rouvio O, Ronson A, Herzog-Tzarfati K, Akria L, Braester A, Hellmann I, Yeganeh S, Nagler A, Leiba R, Mittelman M, Merkel D. Higher infection rate after 7- compared with 5-day cycle of azacitidine in patients with higher-risk myelodysplastic syndrome. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:e95-9. [PMID: 25819366 DOI: 10.1016/j.clml.2015.02.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 02/16/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Azacitidine (AZA) dose reduction is a common practice in cytopenic patients. However, a correlation between AZA dose and infection complications has never been studied. PATIENTS AND METHODS Higher-risk patients with myelodysplastic syndrome or acute myeloid leukemia treated with AZA in 18 Israeli hospitals between the years 2008 and 2011 were included in a former national survey. To reveal the effect of AZA dosage on infection risk we limited our analysis to the infection rate after the first AZA dose alone. We excluded subsequent cycles of AZA from the analysis, because infectious events during these cycles might be related to other cofactors such as disease response to AZA therapy. RESULTS After the first AZA cycle, infectious events were more frequent after doses of 75 mg/m(2) for 7 days than 75 mg/m(2) for 5 days (36/106 [34%] and 10/67 [14.9%], respectively; P = .008), regardless of the patient's age. Of the 46 recorded infectious events, the causative pathogen was identified as bacterial in 25 (54.3%) and as viral or fungal in 2 (4.3%) and 2 (4.3%) cases, respectively. No pathogen was identified in 17 (37%) cases. Infections were significantly more prevalent among patients who presented with platelet counts < 20,000 (43.6% vs. 23.6%; P = .012) and poor risk cytogenetics (40.7% vs. 19.8%; P = .008). CONCLUSION Reduction of AZA dose might decrease infection rate and therefore should be considered in patients with high infection risk.
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Affiliation(s)
- Yishai Ofran
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | | | - Anat Gafter-Gvili
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Tel Aviv University, Tel Aviv, Israel
| | - Liat Vidal
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Aviv
- Department of Hematology, Emek Medical Center, Afula, Israel
| | - Moshe E Gatt
- Hematology Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Yair Herishanu
- Hematology Institute, Sourasky Medical Center, Tel Aviv, Israel
| | - Ariela Arad
- Department of Hematology, Sanz Medical Center - Laniado Hospital, Netanya, Israel
| | - Tamar Tadmor
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel; Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - Najib Dally
- Department of Hematology, Ziv Medical Center, Zefat, Israel
| | - Anatoly Nemets
- Department of Hematology, Barzilai Medical Center, Ashkelon, Israel
| | - Ory Rouvio
- Institution of Hematology, Soroka University Medical Center, Beer-Sheba, Israel
| | - Aharon Ronson
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Luiza Akria
- Department of Hematology, Western Galilee Hospital, Nahariya, Israel
| | - Andrei Braester
- Department of Hematology, Western Galilee Hospital, Nahariya, Israel
| | | | - Shay Yeganeh
- Hematology Unit, Poria Medical Center, Hedera, Israel
| | - Arnon Nagler
- Division of Hematology, Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Leiba
- Quality of Care Unit, Rambam Health Care Campus, Haifa, Israel
| | - Moshe Mittelman
- Department of Medicine, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Drorit Merkel
- Division of Hematology, Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
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17
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Abstract
Febrile neutropenia (FN) can occur at any time during the course of a malignancy, especially hematologic malignancies, from diagnosis to end-stage disease. The majority of FN episodes are typically confined to the period of initial diagnosis and active treatment. Because of suppressed inflammatory responses, fever is often the sole sign of infection. As FN is a true medical emergency, prompt identification of and intervention in FN can prolong survival and improve quality of life. This article reviews FN in the setting of hematologic malignancies, specifically myelodysplastic syndromes and acute leukemias, providing an overview of the definition of fever and neutropenia, diagnostic approach, categories of risk/risk assessment, management in patients at low and high risk, and prophylaxis of infections.
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18
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Laribi K, Denizon N, Ghnaya H, Atlassi M, Besançon A, Pineau-Vincent F, Gaulard P, Petrella T. Blastic plasmacytoid dendritic cell neoplasm: the first report of two cases treated by 5-Azacytidine. Eur J Haematol 2014; 93:81-5. [DOI: 10.1111/ejh.12294] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2014] [Indexed: 12/18/2022]
Affiliation(s)
- Kamel Laribi
- Hematology Department; Centre Hospitalier Le Mans; Le Mans France
| | - Nathalie Denizon
- Hematology Department; Centre Hospitalier Le Mans; Le Mans France
| | - Habib Ghnaya
- Hematology Department; Centre Hospitalier Le Mans; Le Mans France
| | - Mustapha Atlassi
- Hematology Department; Centre Hospitalier Le Mans; Le Mans France
| | - Anne Besançon
- Hematology Department; Centre Hospitalier Le Mans; Le Mans France
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19
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Falantes JF, Calderón C, Márquez-Malaver FJ, Aguilar-Guisado M, Martín-Peña A, Martino ML, Montero I, González J, Parody R, Pérez-Simón JA, Espigado I. Patterns of Infection in Patients With Myelodysplastic Syndromes and Acute Myeloid Leukemia Receiving Azacitidine as Salvage Therapy. Implications for Primary Antifungal Prophylaxis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:80-6. [DOI: 10.1016/j.clml.2013.09.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/07/2013] [Accepted: 09/24/2013] [Indexed: 11/28/2022]
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20
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Kim YJ, Jang JH, Kwak JY, Lee JH, Kim HJ. Use of azacitidine for myelodysplastic syndromes: controversial issues and practical recommendations. Blood Res 2013; 48:87-98. [PMID: 23826577 PMCID: PMC3698413 DOI: 10.5045/br.2013.48.2.87] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 05/24/2013] [Accepted: 05/30/2013] [Indexed: 01/10/2023] Open
Abstract
Azacitidine is recommended for patients with higher-risk myelodysplastic syndromes (MDS) who are not eligible for intensive therapy or for patients with lower-risk MDS who have thrombocytopenia or neutropenia or have anemia that is unresponsive to other therapies. However, standard treatment with azacitidine has not been optimized and many issues about the use of azacitidine remain unresolved. The use of azacitidine is expanding rapidly, but limited comparative clinical trial data are available to (i) define the optimal use of azacitidine in patients with higher-risk MDS or around the time of allogeneic hematopoietic stem cell transplantation, (ii) identify those patients with lower-risk MDS who may benefit from treatment, and (iii) guide physicians on alternative therapies after treatment failure. Increasing evidence suggests that the clinical features, prognostic factors, and cytogenetic profiles of patients with MDS in Asia differ significantly from those of patients in Western countries, so the aim of this review is to summarize the evidence and provide practical recommendations on the use of azacitidine in patients with MDS in the Republic of Korea. Evidence considered in this review is based on published clinical data and on the clinical experience of an expert panel from the acute myeloid leukemia/MDS Working Party of the Korean Society of Hematology.
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Affiliation(s)
- Yoo-Jin Kim
- Department of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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21
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Merkel D, Filanovsky K, Gafter-Gvili A, Vidal L, Aviv A, Gatt ME, Silbershatz I, Herishanu Y, Arad A, Tadmor T, Dally N, Nemets A, Rouvio O, Ronson A, Herzog-Tzarfati K, Akria L, Braester A, Hellmann I, Yeganeh S, Nagler A, Leiba R, Mittelman M, Ofran Y. Predicting infections in high-risk patients with myelodysplastic syndrome/acute myeloid leukemia treated with azacitidine: a retrospective multicenter study. Am J Hematol 2013; 88:130-4. [PMID: 23345248 DOI: 10.1002/ajh.23368] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 11/18/2012] [Indexed: 11/08/2022]
Abstract
Hypomethylating agents have become the standard therapy for patients with high-risk myelodysplastic syndrome (MDS). In Israel, azacitidine (AZA) is routinely used. Yet, infectious complications are common during AZA therapy. The current study was aimed to evaluate the incidence and predisposing risk factors for infections in AZA-treated patients. This retrospective study included patients treated with AZA in 18 Israeli medical institutions between 2008 and 2011. Data on 184 patients [157 high-risk MDS and 27 acute myeloid leukemia (AML)], with a median age of 71.6 (range 29-92) were recorded. Overall, 153 infectious events were reported during 928 treatment cycles (16.5%) administered to 100 patients. One hundred fourteen, 114/153 (75%) events required hospitalization and 30 (19.6%) were fatal. In a univariate analysis, unfavorable cytogenetics, low neutrophil, hemoglobin (Hb) and platelet (PLT) counts were found to be associated with infections (24.4% vs. 12.9%, P < 0.0001; 27% vs. 13.5%, P < 0.0001; 20.4% vs. 11%, P < 0.0001 and 29.2% vs. 14.2%, P < 0.0001, respectively). In multivariate analysis, only low Hb level, low PLT count, and unfavorable cytogenetics remained significant. Prior to therapy, poor cytogenetics, PLT count below 20 × 10⁹/L and neutrophil count below 0.5 × 10⁹/L were predictive of the risk of infection during the first two cycles of therapy. In conclusion, patients with unfavorable cytogenetics, presenting with low neutrophil and PLT counts, are susceptible to infections. Evaluation of infection risk should be repeated prior to each cycle. Patients with poor cytogenetics in whom AZA is prescribed despite low PLT count are particularly at high risk for infections and infection prophylaxis may be considered.
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Affiliation(s)
- Drorit Merkel
- Division of Hematology; Sheba Medical Center, Tel-Hashomer, Tel Aviv University; Israel
| | | | - Anat Gafter-Gvili
- Institute of Hematology; Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Tel Aviv University; Israel
| | - Liat Vidal
- Institute of Hematology; Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Tel Aviv University; Israel
| | - Ariel Aviv
- Department of Hematology; Emek Medical Center; Afula; Israel
| | - Moshe E. Gatt
- Department of Hematology; Hadassah Hebrew University Medical Center; Jerusalem; Israel
| | | | - Yair Herishanu
- Hematology Institute; Sourasky Medical Center; Tel Aviv; Israel
| | - Ariela Arad
- Department of Hematology; Sanz Medical Center, Laniado Hospital; Netanya; Israel
| | | | - Najib Dally
- Department of Hematology; Ziv Medical Center; Zefat; Israel
| | - Anatoly Nemets
- Department of Hematology; Barzilai Medical Center; Ashkelon; Israel
| | - Ory Rouvio
- Institution of Hematology; Soroka University Medical Center; Beer-Sheba; Israel
| | - Aharon Ronson
- Department of Hematology; Shaare Zedek Medical Center; Jerusalem; Israel
| | | | - Luiza Akria
- Department of Hematology; Western Galilee Hospital; Nahariya; Israel
| | - Andrei Braester
- Department of Hematology; Western Galilee Hospital; Nahariya; Israel
| | | | - Shay Yeganeh
- Hematology Unit; Poria Medical Center; Hedera; Israel
| | - Arnon Nagler
- Division of Hematology; Sheba Medical Center, Tel-Hashomer, Tel Aviv University; Israel
| | - Ronit Leiba
- Quality of Care Unit; Rambam Health Care Campus; Haifa; Israel
| | - Moshe Mittelman
- Department of Medicine; Sourasky Medical Center, Tel Aviv University; Israel
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22
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Seidel C, Florean C, Schnekenburger M, Dicato M, Diederich M. Chromatin-modifying agents in anti-cancer therapy. Biochimie 2012; 94:2264-79. [DOI: 10.1016/j.biochi.2012.05.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 05/14/2012] [Indexed: 01/12/2023]
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23
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Toma A, Fenaux P, Dreyfus F, Cordonnier C. Infections in myelodysplastic syndromes. Haematologica 2012; 97:1459-70. [PMID: 22733024 PMCID: PMC3487546 DOI: 10.3324/haematol.2012.063420] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 05/17/2012] [Accepted: 06/13/2012] [Indexed: 12/19/2022] Open
Abstract
Myelodysplastic syndromes are associated with a risk of severe infections. While neutropenia is likely to be the main predisposing factor, several other immune defects have been reported, including impaired neutrophil function, B-, T- and NK-cell defects and the possible consequences of iron overload due to red blood cell transfusions. The advanced age of most patients, their frequent comorbidities, and the fact that drugs such as hypomethylating agents and lenalidomide, which are effective in myelodysplastic syndromes but can transiently worsen neutropenia, may increase the risk of infection and their severity in this context. The majority of infections in myelodysplastic syndromes are bacterial, while the incidence of fungal infections is not well known and viral infections seem to be rare. No prophylactic measures against infections have demonstrated efficacy in myelodysplastic syndromes. However, pending more data, we propose here some recommendations for the management of patients with myelodysplastic syndromes. In the future, an important contribution can be made by prospective trials testing the efficacy of prophylactic and therapeutic approaches to infection in these patients, especially in the context of the new drugs available for myelodysplastic syndromes.
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Affiliation(s)
- Andréa Toma
- Department of Hematology Henri Mondor University Hospital, 94000 Créteil, France.
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24
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Abstract
PURPOSE OF REVIEW Hypomethylating agents (HMAs) improve the outcome of higher-risk myelodysplastic syndromes (MDS) and provide multilineage response in lower-risk patients but their results must be optimized, especially as the poor outcome of patients after HMA failure is now established. RECENT FINDINGS Current efforts include evaluation of novel outpatient administration schedules and routes, improving compliance and drug exposure to reach continuous hypomethylation. Novel combination strategies are emerging, with histone deacetylase inhibitors or immunomodulatory compounds, but none has proven superior to HMA single-agent therapy so far. Improved understanding of the epigenetic deregulation of MDS and of HMA's mode of action has allowed putative biomarkers to emerge, including multiple gene methylation patterns, and gene mutations, notably TET2 mutations. As HMAs may elicit antileukemic immune responses, they are also being evaluated in patients eligible for allogeneic stem cell transplantation. SUMMARY The indication and practical use of HMAs in MDS so far remain those of phase III registration studies, but will hopefully be modified with future results of ongoing clinical and translational research.
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25
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Yagisawa K, Okazuka K, Toba K, Urushiyama M, Kuroha T, Izumi N, Sibasaki Y, Higashimura M, Yano T, Momoi A, Hattori A, Momotsu K, Aizawa Y. Features of Japanese patients with myelodysplastic syndrome in an aging population of Sado Island. Int J Hematol 2012; 95:420-7. [PMID: 22362009 DOI: 10.1007/s12185-012-1031-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 02/15/2012] [Accepted: 02/15/2012] [Indexed: 11/27/2022]
Abstract
Myelodysplastic syndrome (MDS) is relatively common in the elderly, and aging of populations is progressing in developed nations, notably so in Japan. The major age group in Japan and Sado Island are distributed between 30 and 60 and between 50 and 80, respectively. The aim of this study was to analyze the features of MDS in the population of Sado Island to anticipate the characteristics of the disease in the near future. One-hundred and fifty-three patients (71 male, 82 female, 19-94 years old, median 73 years old) with de novo MDS between 1985 and 2005 were retrospectively evaluated. All patients were reclassified according to WHO-2001 criteria. The predictive power of the international prognostic scoring system and the WHO classification-based prognostic scoring system were evaluated. The major causes of death were leukemic transformation (38%) in refractory anemia with an excess of blasts and infection (48%) for total MDS. Age was another independent prognostic factor. Elderly patients exhibited a significantly poorer prognosis mainly due to infections such as pneumonia. Although novel remedies for MDS and hyperferremia have recently been developed, prevention of infection remains important in MDS, particularly for older patients.
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Affiliation(s)
- Kumiko Yagisawa
- Department of Internal Medicine, Sado Sogo Hospital, Niigata, Japan
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Abstract
PURPOSE OF REVIEW Antibiotic prophylaxis has been found to have multiple benefits in patients receiving intensive chemotherapy at high risk for infection. Interest continues in identifying what additional groups of high-risk patients might potentially benefit from its use. However, concerns about the potential emergence of antibiotic resistance have led to multiple recent studies exploring this issue. RECENT FINDINGS The use of antibiotic prophylaxis in pediatric leukemia, myelodysplastic syndromes, and hematopoietic stem cell transplant populations has been evaluated in recent studies. Several centers have noted increased rates of antibiotic resistance in patients receiving prophylaxis. SUMMARY Several single-center studies have emphasized the concern for the emergence of antibiotic resistance associated with the routine use of fluoroquinolone prophylaxis. The potential for antibiotic resistance continues to be worrisome and warrants further ongoing studies.
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Lee JH, Jang JH, Park J, Park S, Joo YD, Kim YK, Kim HG, Choi CW, Kim SH, Park SK, Park E, Min YH. A prospective multicenter observational study of decitabine treatment in Korean patients with myelodysplastic syndrome. Haematologica 2011; 96:1441-7. [PMID: 21659363 PMCID: PMC3186304 DOI: 10.3324/haematol.2011.046078] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 05/19/2011] [Accepted: 05/23/2011] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Decitabine was evaluated for its efficacy and safety in Korean patients with myelodysplastic syndrome with IPSS score of 0.5 or over. DESIGN AND METHODS Decitabine 20 mg/m(2)/day was given intravenously over one hour for five consecutive days every four weeks. The primary end point was overall response rate. RESULTS A total of 101 patients were analyzed. The International Prognostic Scoring System risk category was Intermediate-2/High in 47.5%. A median of 5 courses (range 1-18) were delivered. The overall response rate was 55.4% (13 complete responses, one partial response, 23 marrow complete responses, and 19 hematologic improvements). Forty-eight patients (47.5%) showed some hematologic improvement. With a median follow-up duration of 478 days (range 69-595), median overall survival was 17.7 months. Patients who showed hematologic improvement had significantly longer overall survival than those who did not (19.2 vs. 15.9 months, P=0.006 by landmark analysis at six months). The difference in overall survival was evident in the Intermediate-2/High risk group but not in the Intermediate-1 risk group. The progression-free survival and acute myeloid leukemia-free survival were 61.9% and 77.9% at one year, respectively. Among 489 assessable treatment courses, there were 97 fever episodes requiring intravenous antimicrobials. CONCLUSIONS Decitabine treatment was feasible and effective in Korean patients with myelodysplastic syndrome, and the overall survival was significantly longer in patients showing hematologic improvement.
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Affiliation(s)
- Je-Hwan Lee
- Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Jun Ho Jang
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Jinny Park
- Gachon University Gil Hospital, Gachon University of Medicine and Science School of Medicine, Incheon
| | | | - Young-Don Joo
- Haeundae Paik Hospital, Inje University College of Medicine, Busan
| | | | - Hoon-Gu Kim
- Gyeongsang National University Hospital, Jinju
| | | | | | | | | | - Yoo Hong Min
- Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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