Anti-infective prophylaxis in pediatric patients with acute myeloid leukemia

Abstract

Pediatric patients undergoing treatment for acute myeloid leukemia (AML) are at high risk for infectious complications, predominantly due to Gram-negative bacteria, viridans group streptococci and fungal pathogens. In order to prevent infections in these patients, most institutions have implemented a number of non-pharmacological approaches to supportive care. In addition, antibiotic prophylaxis reduces bacterial infection, but may increase the emergence of resistance. Antifungal prophylaxis is generally recommended for children with AML. Whereas the use of hematopoietic growth factors has not resulted in improved survival, the efficacy of prophylactic granulocyte transfusions has to be determined.

Keywords::

• acute myeloid leukemia
• bacteria
• child
• fungus
• granulocyte transfusion
• hematopoietic growth factor
• infection

Financial & competing interests disclosure

T Lehrnbecher served in the speaker’s bureau of Astellas, Gilead Sciences, GlaxoSmithKline, Merck/MSD and Pfizer; he also received a research grant from Gilead Sciences and is a consultant to Astellas, Gilead Sciences and Merck/MSD. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Both children and adult with acute myeloid leukemia (AML) have a high risk for infectious complications, in particular for infections due to Gram-negative bacteria, viridans group streptococci and fungal pathogens.

• The benefit of many of non-pharmacological anti-infective measures (e.g., low bacterial diet, prolonged hospitalization during neutropenia) is unclear.

• The prophylactic use of antibiotics may decrease the risk for Gram-negative and Gram-positive bacterial infections.

• The use of prophylactic antibiotics must be balanced against the risk of emerging resistance and other adverse events.

• Antifungal prophylaxis, including TMP/SMX for prophylaxis of Pneumocystis jirovecii, should be administered to all children with AML.

• Whereas prophylactic posaconazole has been shown in adults with AML to reduce mortality, this compound is not licensed for use in children younger than 13 years, and its dosage has not yet been defined for young children in the prophylactic setting.

• The prophylactic use of hematopoietic growth factors such as G-CSF and granulocyte-macrophage colony-stimulating factor does not decrease mortality in children with AML.

• The benefit of granulocyte transfusions to prevent severe infectious complications is unclear.