Adenovirus infection among pediatric patients with cancer and in pediatric recipients of hematopoietic stem cell: A multicenter nationwide study

The aim was to evaluate the incidence, clinical course, and outcome of adenoviral infection (AdVI) in pediatric patients diagnosed and treated due to cancer and in pediatric recipients of hematopoietic stem cell. Over a 72-month period, all-in 5599 children with cancer: 2441 patients with hematological malignancy (HM) and 3158 with solid tumors (ST), and 971 patients after transplantation: 741 after allogeneic (allo-HSCT) and 230 after autologous (auto-HSCT) were enrolled into the study. Among cancer patients, 67 episodes of AdVI appeared in 63 (1.1%) children, including 45 (1.8%) with HM and 18 (0.6%; P < .001) with ST. Within transplanted patients, AdVIs were responsible for 88 episodes in 81 (8.3%) children (P < .001), including 78 (10.5%) patients after allo-HSCT and 3 (1.3%) after auto-HSCT. Time to develop AdVI was short, especially after allo-HSCT. The most common clinical manifestation in cancer patients was enteritis diagnosed in 63 (94.0%) cases, while among HSCT recipient asymptomatic adenoviremia was found in 36 (40.9%) cases and the most common clinical manifestation was urinary tract infection. Cancer patients with disseminated disease, as well as HSCT recipients with either asymptomatic viremia or disseminated disease, received antiviral treatment. The most commonly used first-line therapy was cidofovir. None of the cancer patients died due to AdVI, while within HSCT recipients three patients developed disseminated adenoviral disease and died despite antiviral treatment. In cancer patients, AdVIs are rare and associated with very good prognosis even without specific treatment. However, in allo-HSCT recipients, disseminated disease with fatal outcome is more likely to occur.

Hematopoietic stem cell transplantation does not increase the risk of infection-related complications for pediatric patients with Hodgkin and non-Hodgkin lymphomas: A multicenter nationwide study

BACKGROUND

Hodgkin (HL) and non-Hodgkin lymphoma (NHL) represent a spectrum of lymphoid malignancies that are often curable with currently applied treatment regimens; however, 15%-30% of lymphoma patients still suffer from relapsed or refractory (rel/ref) disease. Although hematopoietic stem cell transplantation (HSCT) improves outcomes of second-line therapy for lymphoma in childhood, the complication rates in this group of patients, especially infectious complications (IC), remain unclear.

OBJECTIVE

The aim of this population-based cohort study was a retrospective analysis of incidence, epidemiology and profile of bacterial infections (BI), invasive fungal disease (IFD), and viral infections (VI) in primary or rel/ref lymphoma patients, both HL and NHL.

PATIENTS AND METHODS

We subdivided lymphoma patients into three groups: patients with primary conventional chemotherapy/radiotherapy regimens (group A), patients with rel/ref lymphoma treated with second-line chemotherapy (group B), and rel/ref lymphoma patients who underwent HSCT (group C). The medical records of the patients were biannually reported by each pediatric oncology center, and the data were analyzed centrally.

RESULTS

Within 637 patients with primary lymphoma, at least one IC was diagnosed in 255 (40.0%), among 52 patients with rel/ref lymphoma 24 (46.2%) ICs were observed, and in transplanted group, 28 (57.1%) out of 49 children were diagnosed with IC (P = .151). The distribution of etiology of IC differed between the patient groups (A, B, C), with a predominance of BI in group A (85.6% vs 72.0% and 47.9%, respectively), VI in group C (9% and 16.0% vs 46.6%, respectively), and IFD in group B (5.4% vs 12.0% vs 5.5%, respectively). Overall, 500 (68.0%) episodes of bacterial IC were diagnosed in the entire group. Apart from HL patients treated with chemotherapy, in all the other subgroups of patients Gram-positives were predominant. The rate of multidrug-resistant bacteria was high, especially for Gram-negatives (41.1% in group A, 62.5% in group B, and 84.6% in group C). The infection-related mortality was comparable for each group.

CONCLUSIONS

The incidence of IC was comparable during first- and second-line chemotherapy and after HSCT, but their profile was different for primary or re/ref lymphoma and depended on the type of therapy.

Multidrug-resistant bacterial infections in children undergoing haematopoietic stem cell transplantation over a 6-year period: analysis of the Polish Pediatric Group for Hematopoietic Stem Cell Transplantation

AIMS

Multidrug-resistant (MDR) bacteria are an emerging cause of morbidity and mortality after haematopoietic stem cell transplantation (HSCT). The aim of the study was to analyse the incidence, clinical characteristics and survival from bacterial infections (BI) caused by MDR pathogens in paediatric HSCT recipients.

METHODS AND RESULTS

Among 971 transplanted patients, BI were found in 416 children between the years 2012 and 2017. Overall, there were 883 bacterial episodes, which includes 85·8% after allo-HSCT and 14·2% after auto-HSCT. MDR strains were responsible for half of the total number of bacterial episodes. Over 50% of MDR pathogens were Enterobacteriaceae causing mainly gut infections or urinary tract infections.

CONCLUSIONS

Regarding HSCT type, we did not find differences in the profile of MDR BI between allo- and auto-HSCT recipients. However, survival in MDR and non-MDR infections was comparable.

SIGNIFICANCE AND IMPACT OF THE STUDY

The large sample size enables unique analysis and makes our data more applicable to other paediatric HSCT centres. In the absence of local epidemiological data, presented clinical characteristics of MDR-caused infections may be used to optimize the prophylactic strategies, early identification of infectious complications of MDR aetiology and thus promptly initiate adequate antibiotic therapy and further improve patients' outcome.

Incidence, course, and outcome of Clostridium difficile infection in children with hematological malignancies or undergoing hematopoietic stem cell transplantation

Clostridium difficile infection (CDI) is one of the most common causes of nosocomial infectious diarrhea in children during anticancer therapy or undergoing hematopoietic stem cell transplantation (HSCT) in Europe. Immunosuppression in these patients is a risk factor for CDI. Malignant diseases, age, acute graft-versus-host disease (aGVHD), HLA mismatch, or use of total body irradiation may play an important role in CDI course. The aim of this study was to evaluate the incidence, course, and outcome of CDI in children treated for malignancy or undergoing HSCT. Between 2012 and 2015, a total number of 1846 patients were treated for malignancy in Polish pediatric oncological centers (PHO group) and 342 underwent transplantation (HSCT group). In PHO group, episodes of CDI occurred in 210 patients (14%). The incidence of CDI was higher in patients with hematological malignancies in comparison to that with solid tumors. Patients with acute myeloblastic leukemia had shorter time to episode of CDI than those with acute lymphoblastic leukemia. Patients over 5 years and treated for acute leukemia had more severe clinical course of disease in PHO group. In HSCT group, CDI occurred in 29 (8%) patients. The incidence of CDI was higher in patients transplanted for acute leukemia. The recurrence rate was 14.7% in PHO and 20.7% in HSCT patients. CDI incidence was highest in patients with hematological malignancies. Most of patients experienced mild CDI. Age < 5 years and diagnosis other than acute leukemia were the positive prognostic factors influencing clinical CDI course.

Incidence of Infectious Complications in Children With Acute Lymphoblastic Leukemia Treated With Hematopoietic Stem Cell Transplantation

OBJECTIVE

We analyzed incidence and profile of infections in children with acute lymphoblastic leukemia (ALL) treated with hematopoietic stem cell transplantation (HSCT) in Polish pediatric HSCT departments, over a 2-year period.

PATIENTS AND METHODS

Hospital records of 67 patients, who underwent allogeneic HSCT for ALL, were analyzed retrospectively for microbiologically documented infection: bacterial infection (BI), viral infection (VI), and fungal infection (FI). The majority of patients (40/67; 59.7%) underwent HSCT from matched unrelated donors (MUD).

RESULTS

In total, 84 BI in 31 patients, 93 VI in 50 patients, and 27 FI in 22 patients were diagnosed. No differences were found in the frequency of occurrence of BI according to the type of transplant (P = .16); the occurrence of VI was statistically more frequent in MUD transplant recipients as compared with matched sibling donors (MSD) and mismatched related donors (MMFD; P = .001) and there was a trend in MUD patients for the higher occurrence of FI in comparison with MSD and MMFD transplants (P = .08). Regarding disease status, the occurrence of BI, VI, and FI was statistically more frequent in children who underwent transplantation in their first complete remission (CR1), rather than those who underwent transplantation in ≥CR2 (P < .05). In conclusion, infectious complications are an important cause of morbidity in children with ALL treated with allogeneic HSCT and the incidence of infections is high in this group of patients.

Bacterial infections in pediatric hematopoietic stem cell transplantation recipients: incidence, epidemiology, and spectrum of pathogens: report of the Polish Pediatric Group for Hematopoietic Stem Cell Transplantation

BACKGROUND

Infectious complications are a significant cause of hematopoietic stem cell transplantation (HSCT) failure, especially allogeneic HSCT (allo-HSCT) because of delayed immune reconstitution and graft-versus-host disease (GVHD) occurrence. Identifying the factors responsible for bacterial infections (BI) in patients undergoing HSCT will provide much more effective empirical antimicrobial treatment in this group of patients.

OBJECTIVE

The aim of this study was to evaluate the epidemiology and profile of BI in patients after HSCT in 5 centers of the Polish Pediatric Group for Hematopoietic Stem Cell Transplantation in 2012-2013.

PATIENTS AND METHODS

In 308 HSCT recipients, we retrospectively analyzed 273 episodes of BI in 113 (36.7%) children aged 0.02-22 years (median age: 7 years), 92 after allo-HSCT and 22 after autologous HSCT (auto-HSCT). We assessed incidence of BI in different HSCT types by calculating the Index of Bacterial Infection (IBI) as a ratio of patients with at least 1 BI to all patients who underwent this type of HSCT in the analyzed period. We assessed the profile of BI with particular emphasis on multidrug-resistant organisms, and impact of underlying disease and of graft-versus-host disease on BI episodes.

RESULTS

In the studied group, 273 episodes of BI were diagnosed, including 237 episodes after allo-HSCT and 36 after auto-HSCT. Among allo-HSCT recipients diagnosed with at least 1 BI, the IBI was 0.4 (matched sibling donor-HSCT 0.3; matched donor-HSCT 0.4; mismatched unrelated donor [MMUD]-HSCT 0.8; P = 0.027) and after auto-HSCT 0.3 per 1 transplanted patient. In patient after allo-HSCT because of myelo- or lymphoproliferative diseases and bone marrow failures, the major cause of infections was Enterobacteriaceae, while gram-positive bacteria predominated in the group with primary immunodeficiencies. In all patients after auto-HSCT, the dominant pathogen of BI were Enterobacteriaceae (P = 0.011). Time from each type of HSCT to infection caused by different pathogens did not differ significantly.

CONCLUSIONS

The risk of BI does not depend on the underlying disease, but only on HSCT donor type and is the highest after MMUD-HSCT procedure. The profile of BI depends on the underlying disease and HSCT donor type, but does not depend on the occurrence of acute GVHD. Gram-negative bacteria predominated in patients with myelo- and lymphoproliferative diseases, while in patients with primary immunodeficiencies gram-positive strains were predominant.

Current practices used for the prevention of central venous catheter-associated infection in hematopoietic stem cell transplantation recipients: a survey from the Infectious Diseases Working Party and Nurses' Group of EBMT

BACKGROUND

Central line-associated bloodstream infection (CLABSI) is one of the most common infectious complications after hematopoietic stem cell transplantation. To prevent this complication, international guidelines recommend the implementation of the CLABSI 'prevention bundle' consisting of hand hygiene, full barrier precautions, cleaning the insertion site with chlorhexidine, avoiding femoral sites for insertion, and removing unnecessary catheters. The aim of this survey was to analyze to what extent European Group for Blood and Marrow Transplantation (EBMT) centers have included the CLABSI prevention bundle in practice.

METHODS

A questionnaire used for data collection was sent to the 545 EBMT centers worldwide, 103 of which responded.

RESULTS

All 5 components of the CLABSI prevention bundle were recorded in 28% of the centers' standard operating procedures (SOP), and 21% of the centers answered that they used all of the bundle components in clinical practice. The most common recommendation absent from the SOP was specification of all the components of full barrier precautions (43% of the centers did not include at least 1 component). Skin disinfection with chlorhexidine before catheter insertion was reported by 66% centers. CLABSI rates were monitored in 21% of centers.

CONCLUSIONS

Although most of the centers lacked 1 or more of the CLABSI prevention bundle components in their SOP, improvements could easily be made by updating the centers' SOP. The first important step is introduction of CLABSI rate monitoring in this high-risk patient population.

The effect of doxorubicin on the expression of cyclin A in K-562 leukemia cell line

Two opposite processes such as apoptosis and cell division cycle play an important role in cancer biology. During apoptosis cells die by degrading proteins and genome, whereas in the cell cycle cells divide and the genome is duplicated. There are very few studies on the role of cell cycle proteins in apoptosis although their role is distinctly different from that in the cell cycle. The significance of expression of cyclin A and other cyclin cell proteins (eg. Cdk2) in apoptosis remains to be investigated. The aim of this study was to characterize the distribution pattern of cyclin A by using the stereptavidin - biotin - peroxidase technique in K-562 cells treated with doxorubicin. The analysis of cell cycle phases using cytophotometric methods to estimate the cellular response to doxorubicin was also used. Studied cells were treated with doxorubicin in the range 0.5; 5.0 and 10 microM. Expression of cyclin A in K-562 was 32.2; 41.8; 69.9%, respectively, according to doses of doxorubicin. The number of apoptotic cells was increasing together with the increase of doxorubicin doses as well as positive labeling for cyclin A. After doxorubicin treatment decrease of G1/G0 phase and the growth of cell percentage with dose dependent manner at G2/M phase, compared to control was observed. The results allow to suggest that expression of cyclin A may have pro-apoptotic role however more studies are required to clarify whether and what role cyclin A plays in apoptosis.

[High risk acute lymphoblastic leukaemia in children. Preliminary report after introducing a new version of New York (1997) protocol adjusted to the age of the patients. Report of the Polish Paediatric Leukaemia/Lymphoma Study Group]

The paper presents the experience of the Polish Paediatric Leukaemia/Lymphoma Study Group in the treatment of high-risk acute lymphoblastic leukaemia in children using a new version of the New York (1997-1999). Protocol with treatment intensity adjusted according to the age of the patients. From April 1997 to December 1999 a group of 49 children with leukocytosis ranging from 50 900/mm3 to 580 000/mm3 (median 122 000/mm3) and 6 children with leukocytosis below 50 000/mm3 and poor response to steroids were treated with this protocol. Children below 10 years (43 patients) were treated according to the previous protocol, children above 10 years (12 patients) were treated with intensified protocol (high doses of ARA-C in consolidation and intermediate doses of Mtx in maintenance). Induction was identical for all patients. Complete remission was achieved in 92.6% patients. There were 2 relapses. Six children died - 3 without remission, 2 due to a relapse, 1 due to treatment complications. The current opinions concerning classification of HRG-ALL and treatment possibilities in this group of children are discussed.

In vitro comparative antileukemic activity of various glucocorticoids in childhood acute leukemia

Resistance to glucocorticoids is nowadays one of the strongest adverse risk factors in the treatment of childhood acute lymphoblastic leukemia (ALL). Differential in vitro antileukemic activity of various glucocorticoids and their cross-resistance pattern in childhood acute lymphoblastic and myeloblastic leukemia was determined by means of the MTT assay in 49 successfully tested samples of childhood acute leukemia. The equivalent antileukemic concentrations of respective drugs against lymphoblasts in de novo ALL samples were: 35 microM of hydrocortisone; 8 microM of prednisolone; 1.6 microM of methylprednisolone; 0.47 microM of dexamethasone and 0.23 microM of betamethasone. In comparison to initial ALL samples, the group of relapsed ALL was more resistant to: prednisolone (38-fold, p=0.004), dexamethasone (>32-fold, p=0.004), methylprednisolone (37-fold, p=0.039), betamethasone (38-fold, p=0.018) and hydrocortisone (33-fold, p=0.030). The group of acute myeloid leukemia (AML) samples were resistant to: prednisolone (>83-fold, p<0.001), dexamethasone (>32-fold, p<0.004), methylprednisolone (>65-fold, p=0.003), betamethasone (>66-fold, p=0.004) and hydrocortisone (61-fold, p=0.007), when compared to ALL at presentation. A significant cross-resistance between all used glucocorticoids as well as between glucocorticoids and other tested anti-leukemic drugs was found. In some individual cases in vitro glucocorticoid cross-resistance was less pronounced and relatively good antileukemic activity of betamethasone was observed.

[Methotrexate resistance in acute leukemias]

Methotrexate is an important cytostatic drug in therapy of acute lymphoblastic leukemia. Cellular resistance to methotrexate might cause treatment failure. Possible mechanisms of resistance to methotrexate include: decreased accumulation and retention, decreased intracellular polyglutamylation, increased level or mutations of target enzymes, resistance to apoptosis. The literature review shows that resistance to methotrexate might be circumvented by continuous drug infusion in T-ALL, relapsed ALL and in AML. Another possibility to overcome mechanisms of resistance is the use of rationally designed new antifolates, which: can bypass RFC-mediated drug transport, are not dependent on polyglutamylation, have an improved affinity to target enzymes and target also other enzymes.

[Bone marrow cellularity in acute lymphoblastic leukemia of children]

The early response to therapy in childhood acute lymphoblastic leukemia (ALL) is typically assessed by bone marrow status. The clearance of blast cells in peripheral blood and bone marrow during induction therapy was analysed in 38 children (27 precursor-B-ALL and 11 precursor T-ALL) treated according to BFM90 or New York 93 protocols. Leukocyte count and peripheral blood smear taken at diagnosis, day 8, day 14 and day 33 as well as bone marrow cellularity and percentage of blasts on days: 0, 14, 33 were analysed. The number of blasts in bone marrow was correlated to bone marrow cellularity (Spearman's rho = 0.72, p = 0.001). Patients with T-ALL were more frequently resistant to steroids in vivo and reached remission later in comparison to precursor-B-ALL children (p = 0.019), however blasts reduction ratio was comparable in both lineages. Bone marrow cellularity on days 14 and 33 of induction therapy was similar.

[Diagnosis of infectious mononucleosis in children]

Clinical course of infectious mononucleosis was analysed in 36 children. Heterophilic antibodies were found in 27.8% of children at the age of six or less, and in 72.2% of older ones, mainly between 5-15 day of disease. Mild, mainly haematological complications occurred in 13.8% of cases.

[Examination of blood coagulation in Schoenlein-Henoch disease of children]

Analysis of chosen parameters of haemostasis was performed in 20 children with Schoenlein-Henoch purpura. We found decrease of factor XIII level below 70% in 45% of children, increase of APTT in 40% and slight decrease of platelet number in 50% of patients. There was no correlation between haemostasis abnormalities and the course of the disease.

[The course of Schonlein-Henoch disease in children]

We analysed 79 episodes of Henoch-Schonlein purpura in children. Skin manifestations were present in all cases, abdominal symptoms in 51.9%, arthritis or arthralgia in 41.8% and nephritis in 34.2% of the episodes. Skin rash and haematuria with proteinuria were the longest-lasting symptoms. Skin lesions persisted longer in case of disease relapses (p < 0.05). Typically Henoch-Schonlein purpura is a benign, self-limiting disease.

[Evolution of viral hepatitis B markers in children infected with HBV in the first two years of life]

Circumstances of acquiring an infection, spontaneous evolution of markers during 6 years of follow-up, laboratory findings and results of liver biopsies were analysed in 51 children infected with HBV during the first two years of life; 76.5% of them developed chronic carrier state. ALAT values were periodically increased in 34 children (66.6%) and elimination of HBeAg i HBsAg occurred in 17 (33.3%) and 12 children (23.5%), respectively, during the first year of follow-up. Seroconversion was observed only in a few cases in the subsequent years. Anti-HBc IgM antibodies were detectable for a mean period of less than 7 months (p < 0.02) after diagnosis of infection.

[Efficacy of passive and active immunization against HBV infection in children with neoplastic diseases]

The efficacy of 3 schemes of passive and active prevention of HBV infection was evaluated in 47 children with haematologic proliferative diseases. Twenty-six children suffering from leukemia (group I) received passive immunisation (hepatitis B immunoglobulin) in six week intervals during intensive chemotherapy and were vaccinated on maintenance therapy. Thirteen children with Hodgkin or B-non-Hodgkin lymphoma (group II) received active immunisation from the beginning of intensive chemotherapy with two doses of immunoglobulin. Eight children who had completed their therapy (group III) were vaccinated only. Among children who completed vaccinations, 5/8 in group I, 4/7 in group II and 5/5 in group III produced protective anti-HBs levels. Passive/active prophylaxis was successful in most patients suffering from neoplastic diseases and reduced the endemy of HBV infection in our department from 43.3% to 2.56% infected subjects. Among 7 patients vaccinated from the beginning of treatment (group II), 4 of them produced protective levels of anti,-HBs, despite intensive chemotherapy.

[Concurrence of HBs antigen and anti-HBs antibodies in children infected with HBV]

Two cases of concurrence of HBs antigen and antibodies in boys, who acquired HBV infection within the first two years of life are described. Authors discuss possible explanation of that fact.