J Hematol

Journal of Hematology, ISSN 1927-1212 print, 1927-1220 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Hematol and Elmer Press Inc

Journal website https://www.thejh.org

Original Article

Volume 9, Number 4, December 2020, pages 123-131

Treatment-Related Mortality From Infectious Complications in an Acute Leukemia Clinic

Figure 1. Progression-free survival in patients with acute leukemia who died of infectious complications. There is no difference between the types of leukemias. ALL: acute lymphoblastic leukemia; AML: acute myeloblastic leukemia; PFS: progression-free survival.

Figure 2. Overall survival in patients with acute leukemia who died of infectious complications. There is no statistical difference between the two types of leukemias, no difference between relapse or naive leukemia in this Kaplan-Meier curves. A division should be made. ALL: acute lymphoblastic leukemia; AML: acute myeloblastic leukemia; OS: overall survival.

**Table 1.** Characteristics of Patients Who Died of Infectious Complications Between January 2012 and December 2015
Characteristic	Leukemia type	P value
^aChemotherapy received within 45 days prior to death. AIDA: ATRA + idarubicin; ALL: acute lymphoblastic leukemia; AML: acute myeloblastic leukemia; ATRA: all-trans retinoic acid; BFM: Berlin-Frankfurt-Munster chemotherapy [11]; CALGB: Cancer and Leukemia Group B; Hyper-CVAD: hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone; IDA-FLAG: idarubicin, fludarabine, high-dose cytarabine, granulocyte colony-stimulating factor; MEC: mitoxantrone, etoposide, intermediate-dose Ara-C; POMP: 6-mercaptopurine, vincristine, methotrexate, prednisone.
Median age, years (range)	35.2 (15.8 - 71.3)	27.0 (15.8 - 61.2]	45.1 (19.0 - 71.3)	40.2 (23.2 - 70.6)	0.0004
Male/female, n (%)	52 (61.9)/32 (42.5)	35 (68.6)/16 (31.4)	11 (50.0)/11 (50.0)	6 (54.5)/5 (45.5)	0.2691
Previous disease, n (%)					0.0027
ALL	74 (88.1)	48 (94.1)	20 (90.9)	6 (54.5)
AML	1 (1.2)	1 (2.0)	0	0
Blastic plasmacytoid dendritic cell neoplasm	1 (1.2)	1 (2.0)	0	0
Chronic myelogenous leukemia	2 (2.4)	1 (2.0)	0	1 (9.1)
Diffuse large B-cell lymphoma	1 (1.2)	0	0	1 (9.1)
Lung cancer	1 (1.2)	0	0	1 (9.1)
Myelodysplastic syndrome	3 (3.6)	0	1 (4.5)	2 (18.2)
Thyroid carcinoma	1 (1.2)	0	1 (4.5)	0
Relapsed leukemia, n (%)	43 (51.2)	22 (43.1)	12 (54.5)	9 (81.8)	0.0673
Treatment stage at time of death, n (%)
Induction	27 (32.1)	14 (27.5)	7 (31.8)	6 (54.5)
Re-induction	5 (6.0)	3 (5.9)	1 (4.5)	1 (9.1)
First relapse	25 (29.8)	15 (29.4)	8 (36.4)	2 (18.2)
Second relapse	6 (7.1)	4 (7.8)	1 (4.5)	1 (9.1)
Consolidation	9 (10.7)	6 (11.8)	2 (9.1)	1 (9.1)
Maintenance	2 (2.4)	2 (3.9)	0	0
Palliative care	1 (1.2)	0	1 (4.5)	0
Refractory leukemia	9 (10.7)	7 (13.7)	2 (9.1)	0
Chemotherapy regimen^a, n (%)					0.2795
Hyper-CVAD	17 (20.2)	16 (31.4)	0	1 (9.1)
7+3	10 (11.9)	1 (2.0)	6 (27.3)	3 (27.3)
Palliative POMP	10 (11.9)	8 (15.7)	0	2 (18.2)
BFM	8 (9.5)	8 (15.7)	0	0
Cytarabine high dose	5 (6.0)	0	5 (22.7)	0
Larson regimen [9]	5 (6.0)	5 (9.8)	0	0
CALGB regimen [10]	1 (1.2)	1 (2.0)	0	0
Transplant	4 (4.8)	3 (5.9)	1 (4.5)	0
AIDA	1 (1.2)	0	0	1 (9.1)
IDA-FLAG	6 (7.1)	3 (5.9)	3 (13.6)	0
MEC	1 (1.2)	0	1 (4.5)	0
Vincristine/dexamethasone	3 (3.6)	2 (3.9)	0	1 (9.1)
Steroids	1 (1.2)	1 (2.0)	0	0
Blood transfusion	6 (7.1)	2 (3.9)	2 (9.1)	2 (18.2)

Table 1. Characteristics of Patients Who Died of Infectious Complications Between January 2012 and December 2015

Characteristic

Leukemia type

P value

All types (n = 84)

ALL (n = 51)

AML (n = 22)

Other (n = 11)

^aChemotherapy received within 45 days prior to death. AIDA: ATRA + idarubicin; ALL: acute lymphoblastic leukemia; AML: acute myeloblastic leukemia; ATRA: all-trans retinoic acid; BFM: Berlin-Frankfurt-Munster chemotherapy [11]; CALGB: Cancer and Leukemia Group B; Hyper-CVAD: hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone; IDA-FLAG: idarubicin, fludarabine, high-dose cytarabine, granulocyte colony-stimulating factor; MEC: mitoxantrone, etoposide, intermediate-dose Ara-C; POMP: 6-mercaptopurine, vincristine, methotrexate, prednisone.

Median age, years (range)

35.2 (15.8 - 71.3)

27.0 (15.8 - 61.2]

45.1 (19.0 - 71.3)

40.2 (23.2 - 70.6)

0.0004

Male/female, n (%)

52 (61.9)/32 (42.5)

35 (68.6)/16 (31.4)

11 (50.0)/11 (50.0)

6 (54.5)/5 (45.5)

0.2691

Previous disease, n (%)

0.0027

ALL

74 (88.1)

48 (94.1)

20 (90.9)

6 (54.5)

AML

1 (1.2)

1 (2.0)

Blastic plasmacytoid dendritic cell neoplasm

1 (1.2)

1 (2.0)

Chronic myelogenous leukemia

2 (2.4)

1 (2.0)

1 (9.1)

Diffuse large B-cell lymphoma

1 (1.2)

1 (9.1)

Lung cancer

1 (1.2)

1 (9.1)

Myelodysplastic syndrome

3 (3.6)

1 (4.5)

2 (18.2)

Thyroid carcinoma

1 (1.2)

1 (4.5)

Relapsed leukemia, n (%)

43 (51.2)

22 (43.1)

12 (54.5)

9 (81.8)

0.0673

Treatment stage at time of death, n (%)

Induction

27 (32.1)

14 (27.5)

7 (31.8)

6 (54.5)

Re-induction

5 (6.0)

3 (5.9)

1 (4.5)

1 (9.1)

First relapse

25 (29.8)

15 (29.4)

8 (36.4)

2 (18.2)

Second relapse

6 (7.1)

4 (7.8)

1 (4.5)

1 (9.1)

Consolidation

9 (10.7)

6 (11.8)

2 (9.1)

1 (9.1)

Maintenance

2 (2.4)

2 (3.9)

Palliative care

1 (1.2)

1 (4.5)

Refractory leukemia

9 (10.7)

7 (13.7)

2 (9.1)

Chemotherapy regimen^a, n (%)

0.2795

Hyper-CVAD

17 (20.2)

16 (31.4)

1 (9.1)

7+3

10 (11.9)

1 (2.0)

6 (27.3)

3 (27.3)

Palliative POMP

10 (11.9)

8 (15.7)

2 (18.2)

BFM

8 (9.5)

8 (15.7)

Cytarabine high dose

5 (6.0)

5 (22.7)

Larson regimen [9]

5 (6.0)

5 (9.8)

CALGB regimen [10]

1 (1.2)

1 (2.0)

Transplant

4 (4.8)

3 (5.9)

1 (4.5)

AIDA

1 (1.2)

1 (9.1)

IDA-FLAG

6 (7.1)

3 (5.9)

3 (13.6)

MEC

1 (1.2)

1 (4.5)

Vincristine/dexamethasone

3 (3.6)

2 (3.9)

1 (9.1)

Steroids

1 (1.2)

1 (2.0)

Blood transfusion

6 (7.1)

2 (3.9)

2 (9.1)

2 (18.2)

**Table 2.** Site/Nature of Infection in Patients Who Died of Infectious Complications
Site/nature of infection, n (%)	Leukemia type
The site of infection was documented by site of culture and image studies performed to the patients previously to the death (blood culture, urine culture, feces culture, skin biopsy, sinus swap and catheter culture). ALL: acute lymphoblastic leukemia; AML: acute myeloblastic leukemia.
Catheter-associated infection	6 (7.1)	4 (7.8)	2 (9.1)	0
Gastrointestinal tract	8 (9.5)	4 (7.8)	3 (13.6)	1 (9.1)
Kidney	3 (3.6)	2 (3.9)	0	1 (9.1)
Lung	56 (66.7)	32 (62.7)	16 (72.7)	8 (72.7)
Skin	9 (10.7)	8 (15.7)	1 (4.5)	0
Paranasal sinus	2 (2.4)	1 (2.0)	0	1 (9.1)

Table 2. Site/Nature of Infection in Patients Who Died of Infectious Complications

Site/nature of infection, n (%)

Leukemia type

All types (n = 84)

ALL (n = 51)

AML (n = 22)

Other (n = 11)

The site of infection was documented by site of culture and image studies performed to the patients previously to the death (blood culture, urine culture, feces culture, skin biopsy, sinus swap and catheter culture). ALL: acute lymphoblastic leukemia; AML: acute myeloblastic leukemia.

Catheter-associated infection

6 (7.1)

4 (7.8)

2 (9.1)

Gastrointestinal tract

8 (9.5)

4 (7.8)

3 (13.6)

1 (9.1)

Kidney

3 (3.6)

2 (3.9)

1 (9.1)

Lung

56 (66.7)

32 (62.7)

16 (72.7)

8 (72.7)

Skin

9 (10.7)

8 (15.7)

1 (4.5)

Paranasal sinus

2 (2.4)

1 (2.0)

1 (9.1)

**Table 3.** Most Frequently Isolated Organisms From Blood, Urine, Feces, or Bronchoscopy Culture in Patients Who Died of an Infectious Complication, Depending of the Different Type of Chemotherapy and the Number of Treatment in Correlation With the Site and the Microorganism of Infection
Organism, n (%)	Leukemia type
ALL: acute lymphoblastic leukemia; AML: acute myeloblastic leukemia; ESBL: extended-spectrum beta-lactamases.
None isolated	29 (34.5)	19 (37.3)	7 (31.8)	3 (27.3)
Klebsiella oxytoca	1 (1.2)	1 (2.0)	0	0
Staphylococcus aureus	1 (1.2)	1 (2.0)	0	0
ESBL-producing Escherichia coli	12 (14.3)	8 (15.7)	2 (9.1)	2 (18.2)
Acinetobacter baumannii	2 (2.4)	0	1 (4.5)	1 (9.1)
Enterococcus faecium	7 (8.3)	5 (9.8)	2 (9.1)	0
Pseudomonas aeruginosa	5 (6.0)	2 (3.9)	3 (13.6)	0
Stenotrophomonas maltophilia	3 (3.6)	2 (3.9)	1 (4.5)	0
Candida albicans	4 (4.8)	3 (5.9)	1 (4.5)	0
Escherichia coli	2 (2.4)	0	1 (4.5)	1 (9.1)
Klebsiella pneumoniae	4 (4.8)	2 (3.9)	1 (4.5)	1 (9.1)
Staphylococcus epidermis	2 (2.4)	0	0	2 (18.2)
Candida glabrata	2 (2.4)	1 (2.0)	0	1 (9.1)
Aeromonas hydrophila	1 (1.2)	1 (2.0)	0	0
Influenza H1N1	1 (1.2)	0	1 (4.5)	0
Aspergillus flavus	1 (1.2)	1 (2.0)	0	0
Influenza H3N2	1 (1.2)	0	1 (4.5)	0
Serratia marcescens	2 (2.4)	2 (3.9)	0	0
Clostridium difficile	2 (2.4)	1 (2.0)	1 (4.5)	0
Mucormycosis	2 (2.4)	2 (3.9)	0	0

Table 3. Most Frequently Isolated Organisms From Blood, Urine, Feces, or Bronchoscopy Culture in Patients Who Died of an Infectious Complication, Depending of the Different Type of Chemotherapy and the Number of Treatment in Correlation With the Site and the Microorganism of Infection

Organism, n (%)

Leukemia type

All types (n = 84)

ALL (n = 51)

AML (n = 22)

Other (n = 11)

ALL: acute lymphoblastic leukemia; AML: acute myeloblastic leukemia; ESBL: extended-spectrum beta-lactamases.

None isolated

29 (34.5)

19 (37.3)

7 (31.8)

3 (27.3)

Klebsiella oxytoca

1 (1.2)

1 (2.0)

Staphylococcus aureus

1 (1.2)

1 (2.0)

ESBL-producing Escherichia coli

12 (14.3)

8 (15.7)

2 (9.1)

2 (18.2)

Acinetobacter baumannii

2 (2.4)

1 (4.5)

1 (9.1)

Enterococcus faecium

7 (8.3)

5 (9.8)

2 (9.1)

Pseudomonas aeruginosa

5 (6.0)

2 (3.9)

3 (13.6)

Stenotrophomonas maltophilia

3 (3.6)

2 (3.9)

1 (4.5)

Candida albicans

4 (4.8)

3 (5.9)

1 (4.5)

Escherichia coli

2 (2.4)

1 (4.5)

1 (9.1)

Klebsiella pneumoniae

4 (4.8)

2 (3.9)

1 (4.5)

1 (9.1)

Staphylococcus epidermis

2 (2.4)

2 (18.2)

Candida glabrata

2 (2.4)

1 (2.0)

1 (9.1)

Aeromonas hydrophila

1 (1.2)

1 (2.0)

Influenza H1N1

1 (1.2)

1 (4.5)

Aspergillus flavus

1 (1.2)

1 (2.0)

Influenza H3N2

1 (1.2)

1 (4.5)

Serratia marcescens

2 (2.4)

2 (3.9)

Clostridium difficile

2 (2.4)

1 (2.0)

1 (4.5)

Mucormycosis

2 (2.4)

2 (3.9)