Infectious complications in children with acute lymphoblastic leukemia treated in low-middle-income countries

Abstract

Infections are the most important cause of morbidity and mortality in children treated for acute lymphoblastic leukemia (ALL). The rates of infection-associated mortality are up to 10-times higher in low- and middle-income countries (LMIC) than in high-income countries. The prevention, early recognition and management of infectious complications is especially challenging in LMIC because of disease and poverty-related factors, as well as the shortage of trained personnel, supplies, diagnostic tools and adequate organizational infrastructure. Children in LMIC with ALL, who are frequently underweight, are at increased risk of community-acquired pathogens, nosocomial multidrug-resistant pathogens and opportunistic microorganisms. This review summarizes the challenges of managing the major categories of infections in children receiving treatment for ALL and provides updated practical recommendations for preventing and managing these infections in LMIC.

Keywords:

• childhood acute lymphoblastic leukemia
• febrile neutropenia
• immune suppression
• infections
• low- and middle-income countries

Acknowledgements

The authors would like to thanks Vani Shanker, St. Jude Children’s Research Hospital, for editing the manuscript.

Financial & competing interests disclosure

This work was supported by American Lebanese Syrian Associated Charities (ALSAC); however, the funding source was not involved in the study design, data collection, analysis, interpretation, writing, or decision to submit this report. M Caniza participated as a lecturer sponsored by Sanofi Aventis. 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.

Key issues

• Infection is an important cause of morbidity and mortality during the treatment of children with acute lymphoblastic leukemia (ALL) and can be caused by a broad range of pathogens, including bacteria, viruses, parasites and fungi.

• Poverty-related factors such as low parental literacy, suboptimal living conditions, and distance from healthcare facilities hamper the care of infectious complications in low- and middle-income countries (LMIC).

• Care and prevention of infections in children with ALL in LMIC is challenging because of lack or insufficient number of healthcare personnel trained in infection care and prevention, poor healthcare infrastructure, lack of basic medical supplies, inadequate microbiologic infrastructure, equipment and trained personnel, and insufficient institutional policies with poor organizational structure.

• Effective management of infection requires timely access to diagnostics and antimicrobials.

• Effective prevention of infections involves decreasing the duration of poor innate host defenses against infection, improving acquired immunity through vaccines or Igs, practicing good hygiene, using antibiotic prophylaxis for specific at risk patients.

• The rate of infections in LMIC can be reduced by improving availability of trained healthcare providers effective diagnostics, antimicrobials, and supplies for safe vascular access, as well as and improving infrastructure and forging public and private alliances to support cancer care.

Notes