Colonization with multidrug resistant organisms determines the clinical course of patients with acute myeloid leukemia undergoing intensive induction chemotherapy

Abstract

IntroductionThe global spread of multidrug-resistant organisms (MDRO) complicates treatment and isolation measures in hospitals and has shown to increase mortality. Patients with disease- or therapy-related immunodeficiency are especially at risk for fatal infections caused by MDRO. The impact of MDRO colonization on the clinical course of AML patients undergoing intensive induction chemotherapy—a potentially curative but highly toxic treatment option—has not been systematically studied.Materials & methods312 AML patients undergoing intensive induction chemotherapy between 2007 and 2015 were examined for MDRO colonization. Patients with evidence for MDRO before or during the hospital stay of induction chemotherapy were defined as colonized, patients who never had a positive swab for MDRO were defined as noncolonized.ResultsOf 312 AML patients 90 were colonized and 130 were noncolonized. Colonized patients suffered from significantly more days with fever, spent more days on the intensive care unit and had a higher median C-reactive protein value during the hospital stay. These findings did not result in a prolonged length of hospital stay or an increased mortality rate for colonized patients. However, in a subgroup analysis, patients colonized with carbapenem-resistant enterobacteriaceae (CRE) had a significantly reduced 60- and 90-day, as well as 1- and 2-year survival rates when compared to noncolonized patients.ConclusionOur analysis highlights the importance of intensive MDRO screening especially in patients with febrile neutropenia since persisting fever can be a sign of MDRO-colonization. CRE-colonized patients require special surveillance, since they seem to be at risk for death.

Infections Due to Carbapenem-Resistant Bacteria in Patients With Hematologic Malignancies

“…In order to identify the occurrence of CR in HM patients and to understand its epidemiology, we reviewed series and selected case reports that report colonization or infection of HM patients with CR bacteria. These studies were undertaken in different areas of the world, including New York, New Delhi, China, Stockholm, Frankfurt, Roma, Brescia, Athens, Ankara, Cairo, and Haifa in the series studies ( Tables 1 −3; Cattaneo et al, 2012 , 2018 ; Kjellander et al, 2012 ; Schelenz et al, 2013 ; Satlin et al, 2013a , 2016 ; El-Mahallawy et al, 2014 ; Trecarichi et al, 2015 , 2016 ; Wang et al, 2015 , 2017 ; Micozzi et al, 2017 ; Ballo et al, 2019 ), and in United States, Brazil, Spain, Italy, Poland, Turkey, Israel, Japan, China, and Austria in the case reports ( Table 4 ; Muchtar et al, 2012 ; Carattoli et al, 2013 ; Chang et al, 2013 ; Satlin et al, 2013b ; Girmenia et al, 2015 ; Huang et al, 2015 ; Kara et al, 2015 ; Leitner et al, 2015 ; Xing et al, 2015 ; Kantarcioglu et al, 2016 ; Tofas et al, 2016 ; Zhang et al, 2016 , 2018 ; Majewski et al, 2017 ; Piedra-Carrasco et al, 2017 ; Asai et al, 2018 ). When we geolocate the regions that have reported the presence of CR bacteria in HM patients in Figure 1 , it can be observed that all these studies have been reported in regions that are either endemic or have a significant increase in carbapenemase enzymes (a coincidence with regions with high levels of CR bacteria) ( Figure 1 ).…”

“…In comparison, in a review of studies published worldwide before 2012, Falagas et al (2014) estimated that 26 to 44% of deaths worldwide were due to CR (Falagas et al, 2014), and Borer et al (2009) reported the highest attributable mortality rate for CR-K. pneumoniae bacteremia in all comorbidities as 50% with a mortality risk ratio of 3.3 (95% CI, 2.9-28.5) (Borer et al, 2009). Moreover, in a carbapenemase non-endemic European country, CR-colonized HM patients had a significantly reduced 60-and 90-day, as well as 1-and 2-year survival rates when compared to non-colonized patients (Ballo et al, 2019).…”

“…Likewise, CR-K. pneumoniae colonization documented before or after transplant was followed by an infection in 26% of auto-hematopoietic stem cell transplantation (HSCT) and 39% of allo-HSCT CR-colonized patients (Girmenia et al, 2015). AL diagnosis, mostly AML, was the strongest risk factor for overall CR-bacteria colonization and bacteremia occurrence (Ballo et al, 2019).…”

“…As proved with broad-spectrum beta-lactam-resistant Enterobacteria (Woerther et al, 2015), close monitoring CR intestinal carriage can help control their spread and decide on the appropriate initial antimicrobial treatment for vulnerable HM patients with infection. Surveillance of gut colonization in HM populations, at the time of diagnosis and along the course of chemotherapeutic lines and hospitalizations, should be implemented in the most at risk areas we identified (high incidence of carbapenemase bacteria and leukemias), but also in those with a low prevalence of CR to monitor the risk of CR BSI occurrence in HM patients per regions (Ballo et al, 2019).…”

Febrile neutropenia in patients with acute myeloid leukemia: Outcome in relation to qSOFA score, C‐reactive protein, and blood culture findings

“…The other side of the coin is the threat of multidrug resistance, which has even been reported to influence the clinical course of AML. 41,42 Pseudomonas aeruginosa is still relatively sensitive to fluoroquinolones in Finland 43 suggesting possibility to consider prophylaxis.…”