Epidemiology of Febrile Neutropenia Episodes with Gram-Negative Bacteria Infection in Patients Who Have Undergone Chemotherapy for Hematologic Malignancies: A Retrospective Study of 10 Years' Data from a Single Center

Incidence and prevalence of antimicrobial resistance in outpatients with cancer: a multicentre, retrospective, cohort study

BACKGROUND

Infections are the second leading cause of death in patients with cancer and are often caused by resistant bacteria. However, the frequency of antimicrobial resistance (AMR) in outpatients with cancer is not well understood. We aimed to compare the frequency of AMR bacterial pathogens in outpatients with and without cancer.

METHODS

This retrospective cohort study evaluated antimicrobial susceptibility of bacteria isolated from adults (aged ≥18 years) with and without cancer seeking care in 198 outpatient health-care settings in the USA. Data were collected using the BD Insights Research Database. Patients who were not prescribed cancer medications or not admitted to an inpatient cancer unit in the predefined period were categorised as patients without cancer. Patients were included in the cancer cohort if they received medication solely or sometimes indicated for cancer. Data on gender and race or ethnicity were not collected. Non-duplicate and non-contaminant pathogens collected from various samples (ie, blood, intra-abdominal, respiratory, urine, skin or wound, and other) in outpatients were used to assess the coprimary outcomes: overall and source-specific proportions of non-susceptible pathogen isolates with corresponding AMR odds ratios (ORs); and rates of AMR pathogens per 1000 isolates with corresponding AMR incidence rate ratio (IRR) in patients with and without cancer.

FINDINGS

Data were collected between April 1, 2018, and Dec 31, 2022. 53 006 (3·2%) of 1 655 594 pathogens identified were from 27 421 patients with cancer and 1 602 588 (96·8%) were from 928 128 patients without cancer. For Pseudomonas aeruginosa, carbapenem non-susceptibility was higher in pathogen isolates from patients with cancer (816 [14·4%] of 5683) than patients without cancer (10 709 [11·3%] 94 419; OR 1·22 [95% CI 1·13-1·32]). For Enterobacterales, fluoroquinolone non-susceptibility was higher in pathogen isolates from patients with cancer (8662 [28·0%] of 30 867) than patients without cancer (238 479 [21·8%] of 1 095 996; OR 1·44 [1·40-1·47]), as was carbapenem non-susceptibility (472 [1·5%] of 30 867 vs 9165 [0·8%] of 1 095 996; OR 1·89 [1·72-2·07]), multidrug-resistant pathogens (2672 [8·7%] of 30 867 vs 48 962 [4·5%] of 1 095 996; OR 2·03 [1·95-2·11]), and extended-spectrum β-lactamase producers (4343 [16·5%] of 26 327 vs 93 977 [9·4%] of 996 853; OR 1·96 [1·90-2·03]). For Staphylococcus aureus, meticillin resistance was higher in pathogen isolates from patients with cancer (4747 [53·0%] of 8959) than patients without cancer (129 291 [48·3%] of 267 520; OR 1·20 [1·15-1·25]). For Enterococcus spp, vancomycin resistance was higher in pathogen isolates from patients with cancer (1329 [18·6%] of 7145) than patients without cancer (12 333 [9·1%] of 135 772]; ORR 2·20 [2·06-2·34). The rates and corresponding IRRs of AMR pathogens per 1000 isolates was also higher in patients with cancer compared with patients without cancer, particularly for carbapenem non-susceptible P aeruginosa (IRR 2·06 [1·91-2·21]) and vancomycin-resistant enterococci (IRR 3·06 [2·89-3·24]). For all comparisons, p<0·0001.

INTERPRETATION

AMR proportions and IRRs for most key pathogens were up to three-times higher in isolates from outpatients with cancer than those without cancer, highlighting the need for enhanced surveillance, infection prevention, and timely diagnostic stewardship to improve antibiotic prescribing in this population.

FUNDING

AMR Action Fund.

Factors Associated With Complications in Patients With Hematological Malignancies and Febrile Neutropenia: A Cohort Study

Introduction Febrile neutropenia (FN) in patients with hematological malignancy (HM) is associated with multiple hospital complications including mortality. Although different strategies for early detection and prompt treatment have been established, it is a heterogeneous population with risk factors that are difficult to detect. The data available on the prediction of such complications is limited and there lies the importance of characterizing this type of patients in our environment and evaluating the factors related to the adverse outcomes. Methods The study is a retrospective cohort study conducted at San Vicente Foundation University Hospital (HUSVF) and Alma Mater Hospital of Antioquia (HAMA) in Medellín, Colombia, between January 2018 and December 2020, including patients diagnosed with FN who presented FN at the time of diagnosis or up to 30 days after receiving chemotherapy. The main objective was to determine the factors related to mortality and severe complications (ICU admission, need for vasopressors, or need for mechanical ventilation), while the secondary objective was the microbiological characterization of this population. Results Of the 190 FN episodes, 134 (70.5%) had a clinical focus of infection. A causal agent was identified in 125 episodes (65.8%), with the majority being bacteria in 112 cases (92.6%) of the isolates. The most frequently identified bacteria were Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus. Gram-negative bacilli were isolated in 85 (86%) cases, and resistance was present in 38 cases (44.7%), with both extended-spectrum beta-lactamase (ESBL) and Klebsiella pneumoniae Carbapenemase (KPC) detected in nine (10.5%). In 53 (34.4%) episodes, some complications occurred during FN. The 30-day all-cause mortality was 53 (34.4%), with 27 (50.9%) of these cases associated with complications. Of the 45 (86.5%) patients who died from any cause, all did so during their first episode of FN. In the bivariate analysis, the following factors were associated with higher mortality: hypertension (OR 2.58, 95% CI 1.19-5.58; p=0.014), chronic obstructive pulmonary disease (COPD) (OR 10.2, 95% CI 1.11-93.8; p=0.013), chronic kidney disease (OR 4.27, 95% CI 0.975-18.7; p=0.038), prolonged neutropenia (OR 2.34, 95% CI 1.1-4.95; p=0.024), and lactate dehydrogenase (LDH) levels greater than two times the upper normal limit (UNL) (OR 3.24, 95% CI 1.35-7.75; p=0.007). In contrast, normal albumin levels before chemotherapy were associated with lower mortality (OR 0.381, 95% CI 0.15-0.95; p=0.036). In the multivariate analysis, none of the identified factors were statistically significant in predicting complications or mortality. Conclusion No factors related to complications or mortality were found in the multivariate analysis. However, the heterogeneity of the population suggests that these outcomes are not determined by a single factor, and a study with a larger sample may be needed to confirm them.

Assessment value of interleukin-6, procalcitonin, and C-reactive protein early kinetics for initial antibiotic efficacy in patients with febrile neutropenia: A prospective study

BACKGROUND

This study aims to investigate the early kinetics of interleukin 6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) on initial antibiotic efficacy in hematological disorder patients with febrile neutropenia (FN).

METHODS

A total of 40 patients with 43 episodes of FN were enrolled and divided into initial antibiotic effective group (IAE group, n = 24) and initial antibiotic ineffective group (IAI group, n = 19). The levels of IL-6, PCT, and CRP before antibacterial treatment (T0), and 12 h (T1), 24 h (T2), 48 h (T3), and 72 h (T4) post-antibacterial treatment were determined, respectively. Furthermore, the receiver operating characteristic curve (ROC) analysis was performed to evaluate the clinical value of indicators.

RESULTS

In IAE group, the IL-6 levels gradually decreased from T0 to T4, and the CRP levels significantly decreased at 48 to 72 h, whereas both IL-6 and CRP remained at high levels in the IAI group. The PCT levels in both groups increased at the early stage of anti-infection (T1-T2) and reached to peak at T1-T2 in effective group. ROC curve analysis identified IL-6 as a predictive biomarker for initial antibiotic efficacy at 12, 48, and 72 h after treatment, with the AUC of 0.698, 0.744, and 0.821, respectively. In addition, CRP demonstrated predictive ability of initial antibiotics against infection at 24, 48, and 72 h after therapy, with the AUC of 0.724, 0.741, and 0.797, respectively. ROC curve analysis of percentage changes demonstrated that IL-6 percentage change showed predictive ability of antibiotic efficacy at the early stage, and both the IL-6 and CRP percentage changes showed the predictive ability of antibiotic efficacy 48 or 72 h after antibiotics therapy.

CONCLUSION

This study confirmed IL-6 and CRP levels, and the percentage change in IL-6 as the biomarkers for initial antibiotic efficacy prediction in hematological disorder patients with FN.

Pathogenic spectrum and drug resistance of bloodstream infection in patients with acute myeloid leukaemia: a single centre retrospective study

Background

Bloodstream infection (BSI) represent a prevalent complication in haematological malignancies (HMs). Typically, Patients with BSI usually undergo empirical treatment pending pathogen identification. The timely and effective management of BSIs significantly influences patient prognosis. However, pathogen distribution in BSIs exhibits regional variation. In this study, we investigated the clinical characteristics, pathogen spectrum, drug resistance, risk factors of short-term prognosis and long-term prognostic factors of acute myeloid leukemia (AML) patients with BSI at Zhejiang Provincal People's Hospital.

Methods

From 2019 to 2021, a total of 56 AML patients with BSI were treated in the Department of Haematology at Zhejiang Province People's Hospital. Data regarding pathogen spectrum and drug resistance were collected for analysis. The patients were stratified into non-survivor cohort and survivor cohort within 30 days after BSI, and the predictors of 30-days mortality were identified through both univariate and multivariate Logistic regression analyses. Furthermore, Kaplan-Meier survival analysis and Cox regression analysis were employed to ascertain the risk factors associated with poor prognosis in AML patients complicated by BSI.

Results

A total of 70 strains of pathogenic bacteria were isolated from 56 AML patients with BSI. Gram-negative bacteria constituted the predominant pathogens (71.4%), with Klebsiella pneumoniae being the most prevalent (22.9%). Gram-positive bacteria and fungi accounted for 22.9% and 5.7%, respectively. Univariate and multivariate analyses revealed significant differences in total protein, albumin levels, and the presence of septic shock between the non-survivor cohort and the survior cohort 30 days post-BSI. COX regression analysis showed that agranulocytosis duration exceeding 20 days (HR:3.854; 95% CI: 1.451-10.242) and septic shock (HR:3.788; 95% CI: 1.729-8.299) were independent risk factors for poor prognosis in AML patients complicated by BSI. Notably, the mortality rate within 30 days after Stenotrophomonas maltophilia infection was up to 71.4%.

Conclusions

In this study, Gram-negative bacteria, predominantly Klebsiella pneumoniae, constituted the primary pathogens among AML patients with BSIs. Serum albumin levels and the presence of septic shock emerged as independent risk factors for mortality within 30 days among AML patients with BSI. In terms of long-term prognosis, extended agranulocytosis duration exceeding 20 days and septic shock were associated with elevated mortality rates in AML patients with BSI. Additionally, in our centre, Stenotrophomonas maltophilia infection was found to be associated with a poor prognosis. Early intervention for Stenotrophomonas maltophilia infection in our centre could potentially improve patient outcomes.

Clinical Utility of Stepwise Bronchoalveolar Lavage Fluid Analysis in Diagnosing and Managing Lung Infiltrates in Leukemia/Lymphoma Patients With Febrile Neutropenia

PURPOSE

Febrile neutropenia (FN) is a serious complication in hematologic malignancies, and lung infiltrates (LIs) remain a significant concern. An accurate microbiological diagnosis is crucial but difficult to establish. To address this, we analyzed the utility of a standardized method for performing bronchoalveolar lavage (BAL) along with a two-step strategy for the analysis of BAL fluid.

PATIENTS AND METHODS

This prospective observational study was conducted at a tertiary cancer center from November 2018 to June 2020. Patients age 15 years and older with confirmed leukemia or lymphomas undergoing chemotherapy, with presence of FN, and LIs observed on imaging were enrolled.

RESULTS

Among the 122 enrolled patients, successful BAL was performed in 83.6% of cases. The study used a two-step analysis of BAL fluid, resulting in a diagnostic yield of 74.5%. Furthermore, antimicrobial therapy was modified in 63.9% of patients on the basis of BAL reports, and this population demonstrated a higher response rate (63% v 45%; P = .063).

CONCLUSION

Our study demonstrates that a two-step BAL fluid analysis is safe and clinically beneficial to establish an accurate microbiological diagnosis. Given the crucial impact of diagnostic delays on mortality in hematologic malignancy patients with FN, early BAL studies should be performed to enable prompt and specific diagnosis, allowing for appropriate treatment modifications.

Prediction of Multiple Clinical Complications in Cancer Patients to Ensure Hospital Preparedness and Improved Cancer Care

Reliable and rapid medical diagnosis is the cornerstone for improving the survival rate and quality of life of cancer patients. The problem of clinical decision-making pertaining to the management of patients with hematologic cancer is multifaceted and intricate due to the risk of therapy-induced myelosuppression, multiple infections, and febrile neutropenia (FN). Myelosuppression due to treatment increases the risk of sepsis and mortality in hematological cancer patients with febrile neutropenia. A high prevalence of multidrug-resistant organisms is also noted in such patients, which implies that these patients are left with limited or no-treatment options amidst severe health complications. Hence, early screening of patients for such organisms in their bodies is vital to enable hospital preparedness, curtail the spread to other weak patients in hospitals, and limit community outbreaks. Even though predictive models for sepsis and mortality exist, no model has been suggested for the prediction of multidrug-resistant organisms in hematological cancer patients with febrile neutropenia. Hence, for predicting three critical clinical complications, such as sepsis, the presence of multidrug-resistant organisms, and mortality, from the data available from medical records, we used 1166 febrile neutropenia episodes reported in 513 patients. The XGboost algorithm is suggested from 10-fold cross-validation on 6 candidate models. Other highlights are (1) a novel set of easily available features for the prediction of the aforementioned clinical complications and (2) the use of data augmentation methods and model-scoring-based hyperparameter tuning to address the problem of class disproportionality, a common challenge in medical datasets and often the reason behind poor event prediction rate of various predictive models reported so far. The proposed model depicts improved recall and AUC (area under the curve) for sepsis (recall = 98%, AUC = 0.85), multidrug-resistant organism (recall = 96%, AUC = 0.91), and mortality (recall = 86%, AUC = 0.88) prediction. Our results encourage the need to popularize artificial intelligence-based devices to support clinical decision-making.

Mortality-associated clinical risk factors in patients with febrile neutropenia: A retrospective study

•

This study aimed to predict the outcomes of febrile neutropenic patients

•

Septic shock, anemia, AKI, and need for mechanical ventilation were mortality risks

•

Our prediction score is efficacious in discriminating mortality risk group

Objectives

Methods

Results

Conclusions

Antibiotic resistance in the patient with cancer: Escalating challenges and paths forward

Infection is the second leading cause of death in patients with cancer. Loss of efficacy in antibiotics due to antibiotic resistance in bacteria is an urgent threat against the continuing success of cancer therapy. In this review, the authors focus on recent updates on the impact of antibiotic resistance in the cancer setting, particularly on the ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.). This review highlights the health and financial impact of antibiotic resistance in patients with cancer. Furthermore, the authors recommend measures to control the emergence of antibiotic resistance, highlighting the risk factors associated with cancer care. A lack of data in the etiology of infections, specifically in oncology patients in United States, is identified as a concern, and the authors advocate for a centralized and specialized surveillance system for patients with cancer to predict and prevent the emergence of antibiotic resistance. Finding better ways to predict, prevent, and treat antibiotic-resistant infections will have a major positive impact on the care of those with cancer.

Clinical factors predictive of mortality in acute leukemia patients with febrile neutropenia

BACKGROUND

Acute leukemia is mainly treated with chemotherapy leading to febrile neutropenia (FN). There is limited data on clinical factors predictive of mortality in adults with acute leukemia and FN.

METHODS

This was a retrospective cohort study and enrolled adult patients, diagnosed as acute leukemia, and developed FN. The eligible patients were admitted and followed up with mortality as the primary outcome. A stepwise, multivariate logistic regression analysis was used to find predictors for mortality.

RESULTS

There were 203 patients met the study criteria. Of those, 14 patients died (6.89%). AML was the most common type of acute leukemia with FN (64.04%). There were five remaining factors in the final model: AML, FN at admission, prolong broad spectrum antibiotics, lower respiratory tract infection, and Aspergillosis. Only lower respiratory tract infection was significant with adjusted odds ratio of 7.794 (95% CI of 1.549, 39.212). The Hosmer-Lemeshow Chi square was 2.74 (p value 0.907). The lower respiratory tract infection group had higher proportions of Gram negative and fungus than the non-lower respiratory tract infection group; specifically E. coli (p 0.003), and Aspergillus (P < 0.001).

CONCLUSIONS

There were two independent predictors of mortality in acute leukemia patients with FN: septic shock and lower respiratory tract infection regardless of leukemia type or pathogen. E. coli and Aspergillus were more common in those with lower respiratory tract infection than those without. No specific pathogens were found in cases of septic shock.