[Analysis of causes of death during intensive chemotherapy according to treatment protocol AML-BFM 93]

Infection-related mortality and infection control practices in childhood acute myeloid leukemia in a limited resource setting: Experience with the Indonesian national protocol

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.

Infections during induction therapy of protocol CCLG-2008 in childhood acute lymphoblastic leukemia: a single-center experience with 256 cases in China

Background:

Infections remain a major cause of therapy-associated morbidity and mortality in children with acute lymphoblastic leukemia (ALL).

Methods:

We retrospectively analyzed the medical charts of 256 children treated for ALL under the CCLG-2008 protocol in Beijing Children's Hospital.

Results:

There were 65 infectious complications in 50 patients during vincristine, daunorubicin, L-asparaginase and dexamethasone induction therapy, including microbiologically documented infections (n = 12; 18.5%), clinically documented infections (n = 23; 35.3%) and fever of unknown origin (n = 30; 46.2%). Neutropenia was present in 83.1% of the infectious episodes. In all, most infections occurred around the 15^th day of induction treatment (n = 28), and no patients died of infection-associated complications.

Conclusions:

The infections in this study was independent of treatment response, minimal residual diseases at the end of induction therapy, gender, immunophenotype, infection at first visit, risk stratification at diagnosis, unfavorable karyotypes at diagnosis and morphologic type. The infection rate of CCLG-2008 induction therapy is low, and the outcome of patients is favorable.

Serum cystatin C is a suitable marker for routine monitoring of renal function in pediatric cancer patients, especially of very young age

BACKGROUND

Monitoring renal function is crucial in children undergoing chemotherapy. To date, a combination of routine serum creatinine (SCR) monitoring with occasional determination of creatinine clearance ratio (CCR) is widely used as clinical standard for this purpose. Both methods have their limitations regarding diagnostic value (SCR) or practicability (CCR), especially in young children. Diagnostic alternatives, such as glomerular filtration rate (GFR) estimation formulas have not been proved to be superior. The aim of the study was to evaluate whether serum cystatin C (CysC) may have a diagnostic impact on pediatric patients.

PROCEDURE

CysC, SCR, several GFR estimation formulas (Counahan-Barratt, Ghazali-Barratt, Schwartz, Shull, Traub), and CCR were studied in 80 pediatric cancer patients (age range: 0.17-17.9 years) during their chemotherapy. Special attention was given to children under the age of 3 in whom accurate urine collection for CCR is difficult.

RESULTS

All parameters correlated similarly well with CCR. Total accuracy was 66% and 67% for CysC and SCR, respectively. In very young children (<3 years), correlation with CCR was for CysC r = -0.74 with an area under the curve (AUC) of 0.646, and for SCR r = -0.27 with AUC = 0.594. Total accuracy was 60% for CysC, 50% for SCR.

CONCLUSIONS

CysC represents a suitable marker for monitoring renal function in pediatric cancer patients. In young children (<3 years), CysC may have a better diagnostic value than SCR. Future studies should show if CysC can improve renal monitoring by replacing SCR, especially in very young children.

Causes of death--other than progressive leukemia--in childhood acute lymphoblastic (ALL) and myeloid leukemia (AML): the Dutch Childhood Oncology Group experience

We analyzed causes of death, other than resistant disease or relapse, in 875 children with acute lymphoblastic leukemia (ALL) and 229 with acute myeloid leukemia (AML), treated on three different Dutch Childhood Oncology Group (DCOG) ALL and three AML protocols. Overall, 23 (2.6%) ALL and 44 (19.2%) AML patients died. Early death (ED, before remission was reached) occurred in nine ALL (1%) and thirty AML (13.1%) patients, including three and ten deaths before treatment was initiated. Chemotherapy-related mortality in remission (CRM) occurred in nine ALL (1.1%) and eight AML (4.4%) patients. For ALL, both ED and CRM declined over time, although this was not statistically significant. For AML a decrease in ED was observed (from 26% to approximately 10%), but counter-balanced by an increase in CRM (from 3 to 8%), maybe related to the scheduling of intensification blocks in AML-92/94. Including transplant-related mortality, death in CR rates in AML increased from 3 to 15% in the last study. The main cause of ED was hemorrhage, often associated with hyperleucocytosis, and infection for CRM. We conclude that mortality dropped favorably in ALL, but not in AML. Especially for AML, effective but less toxic therapy and better supportive care guidelines need to be developed.

Ulcerated rhabdomyosarcoma as portal of entry for tetanus in a previously nonimmunized child

Infectious diseases represent one of the most important secondary problems related to the treatment of childhood cancer, being the leading cause of death in this population. They are predominantly of bacterial and fungal etiology. The association between tetanus, a bacterial vaccine-preventable disease, and cancer is virtually undescribed. The authors present the case of a previously nonimmunized child, due to his parents' choice, who developed severe tetanus with an ulcerated rhabdomyosarcoma as portal of entry. Due to an unfavorable evolution, the child underwent a hip disarticulation to provide tetanus control. The ulterior tumor management was successful: the child has been off therapy for more than 108 months with no evidence of disease.