1127547 research-article20222022 TAH0010.1177/20406207221127547Therapeutic Advances in HematologyL Vilorio-Marqués, C Castañón Fernández Therapeutic Advances in Hematology Original Research Relevance of infections on the outcomes Ther Adv Hematol 2022, Vol. 13: 1–15 of patients with myelodysplastic syndromes, DOI: 10.1177/ https://doi.org/10.1177/20406207221127547 https://doi.org/10.1177/20406207221127547 20406207221127547 chronic myelomonocytic leukemia, and © The Author(s), 2022. Article reuse guidelines: sagepub.com/journals- acute myeloid leukemia treated with permissions hypomethylating agents: a cohort study from the GESMD Laura Vilorio-Marqués, Christelle Castañón Fernández, Elvira Mora, Lorena Gutiérrez, Beatriz Rey Bua, Maria José Jiménez Lorenzo, Marina Díaz Beya, Miriam Vara Pampliega, Antonieta Molero, Joaquín Sánchez-García, Marisa Calabuig, Maria Teresa Cedena, Tzu Chen-Liang, Johana Alejandra Díaz Santa, Irene Padilla, Francisca Hernández, Rosana Díez, Pedro Asensi, Blanca Xicoy, Guillermo Sanz, David Valcárcel, María Diez-Campelo and Teresa Bernal Abstract Background: The consequences of infectious toxicity of hypomethylating agents (HMAs) on Correspondence to: Teresa Bernal overall survival (OS) of patients diagnosed with high-risk myeloid neoplasms have not been Hematology Department, Hospital Universitario thoroughly investigated. Central de Asturias, Objectives: We aimed to evaluate whether infectious events (IEs) negatively influenced the Instituto de Investigación Sanitaria del Principado de results of HMA treatment in a real-world setting. Asturias Design: Observational study. Instituto Universitario de Oncología del Principado Methods: We obtained data from 412 non-selected consecutive patients from 23 Spanish de Asturias hospitals who were diagnosed with high-risk myelodysplastic syndrome, chronic Departamento de Medicina, Universidad de myelomonocytic leukemia, or acute myeloid leukemia and were treated with HMA. HMAs Oviedo received after chemotherapy or stem cell transplant were excluded. All IEs were recorded. CIBER enfermedades respiratorias, Madrid, Outcomes included OS, modifications to the pre-planned treatment, incidence and Spain characteristics of IEs, hospitalization, red blood cell transfusions, and factors associated with bernalmaria@uniovi.es infection. Laura Vilorio-Marqués Christelle Castañón Results: The rate of infection was 1.2 per patient/year. Next-cycle delay (p = 0.001) and Fernández Instituto de Investigación hospitalizations (p = 0.001) were significantly influenced by IEs. Transfusion requirements Sanitaria del Principado de during each cycle were significantly higher after infection compared with cycles without Asturias, Oviedo, Spain Elvira Mora infection (coefficient = 1.55 [95% confidence interval (CI) = 1.26–1.84], p < 0.001). The median Pedro Asensi number of cycles was lower in patients experiencing any infection during the first four Guillermo Sanz Hematology Department, cycles (5 [3–8] versu 8 [5–16], p < 0.001). In the multivariable analysis, factors associated Hospital Universitario with lower OS were having any infection during the first four cycles (hazard ratio (HR) = 1.43 y Politécnico La Fe, Valencia, Spain [95% CI = 1.09–1.88], p = 0.01), bone marrow blasts ⩾30% (HR = 2.13 [95% CI = 1.14–3.96], Lorena Gutiérrez p = 0.01), adverse cytogenetics (HR = 1.70 [95% CI = 1.30–2.24], p < 0.001), and platelet Hematology Department, Hospital Universitario count <50 × 109/l (HR = 1.69 [95% CI = 1.3–2.2], p < 0.001). BM blasts >20% (HR = 1.57 [95% de Canarias, La Laguna, CI = 1.19–2.01], p < 0.001) and adverse cytogenetics (HR = 1.7 [95% CI = 1.35–2.14], p < 0.001) Spain Beatriz Rey Bua were associated with infection, whereas hemoglobin >9 g/dl (HR = 0.65 [95% CI = 0.51–0.82], Hematology Department, p < 0.001) and higher platelet count (HR = 0.997 [95% CI = 0.996–0.998], p = 0.016) protected Hospital Clínico Universitario, Salamanca, from it. Spain journals.sagepub.com/home/tah 1 Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Therapeutic Advances in Hematology Volume 13 Maria José Jiménez Conclusion: HMA infectious toxicity worsens OS, hinders the adherence to antineoplastic Lorenzo Blanca Xicoy treatment and results in significant morbidity. Preventive strategies are fundamental in Hematology Department, vulnerable patients. Hospital Germans Trias i Pujol, Institut Català d’Oncologia-Josep Carreras, Leukemia Keywords: acute myeloid leukemia, hypomethylating agent, infection, myelodysplastic Research Institute, Universitat Autònoma de syndrome, treatment outcome Barcelona, Barcelona, Spain Received: 16 January 2022; revised manuscript accepted: 1 September 2022. Marina Díaz Beya Hematology Department, Hospital Clínico Barcelona, Barcelona, Spain María Diez-Campelo Hematology Department, Introduction Methods Hospital Clínico The clinical efficacy of hypomethylating agents Universitario, Salamanca, Spain (HMAs) for the treatment of myelodysplastic Study design and patients Miriam Vara Pampliega syndromes (MDSs), chronic myelomonocytic This was a retrospective study from patients who Hematology Department, leukemia (CMML), and acute myeloid leukemia were prospectively included in the Spanish Hospital Universitario Cruces, Barakaldo, Spain (AML) in real-world practice is lower than Registry of myelodysplastic syndrome (RESMD). Antonieta Molero expected from clinical trials.1,2 This discrepancy David Valcárcel Hematology Department, has been explained as the consequence of selec- Inclusion criteria were diagnosis of high-risk Hospital Universitari Vall tion bias that hinders the inclusion of patients MDS, AML, or CMML-2 according to the World d’Hebrón, Barcelona, Spain with comorbidities or poor performance status in Health Organization (WHO) criteria and first-line Joaquín Sánchez-García these studies. treatment with azacitidine or decitabine following Hematology Department, the European Medicines Agency–approved indi- Hospital Universitario Reina Sofía, Cordoba, Similarly, the possibility of a higher-than-expected cations.7,8 Inclusion of low-risk MDS patients was Spain toxicity in unselected populations could be raised. allowed if platelet counts were <30 × 109/l, abso- Marisa Calabuig One of the characteristic toxicities of these drugs lute neutrophil count (ANC) <0.5 × 109/l, or Hematology Department, Hospital Clínico de is infection. In fact, while HMAs are considered grade 2–3 bone marrow (BM) fibrosis was pre- Valencia, Valencia, Spain safe drugs in this regard, infections are not sent. Similarly, patients with CMML-1 were Maria Teresa Cedena uncommon.3 The impact of infections on lower- included if transfusional dependency or thrombo- Hematology Department, Hospital Universitario ing overall survival (OS) has been addressed in cytopenia <30 × 109/l was present. HMA pre- Doce de Octubre, Madrid, small-scale studies with limited follow-up times.4,5 scriptions after intensive chemotherapy or Spain Tzu Chen-Liang Infectious events (IEs) may cause mortality per se hematopoietic stem cell transplant were excluded. Hematology Department, or may diminish the efficacy of antineoplastic Hospital Universitario Morales Messeguer, treatment by preventing its administration The revised International Prognostic Score Murcia, Spain according to the recommended dose and timing. System and CMML Prognostic Score System Johana Alejandra Díaz In the case of HMAs, the relationship between (IPSS-R and CPSS)9,10 were used in MDS and Santa Hematology Department, infection, adherence to antineoplastic treatment, CMML, respectively. The cytogenetic category Institut Catalá de and survival has not been established.6 was established following Schanz, CPSS, and Oncología, Girona, Spain European Leukemia Net classifications for MDS, Irene Padilla Hematology Department, In this context, we hypothesized that the infec- CMML, and AML, respectively.10–12 Complejo Asistencial tious toxicity experienced by patients treated with Universitario de León, Castilla y León, Spain HMA is higher than the reported in clinical trials, Francisca Hernández leading to reduced tolerance to treatment or even Infections Hematology Department, to an excess of mortality. In line with this hypoth- All IEs were recorded. Hospital Universitario Virgen de las Nieves, esis, the main objective of this multicenter study Granada, Spain was to evaluate the impact of IEs occurring dur- Information on infection was extracted from Rosana Díez Hematology Department, ing HMA treatment on the survival of patients detailed review of the patients’ medical records. Hospital Universitario with high-risk MDS, CMML, or AML. For this Category of infection was defined according to Miguel Servet, Zaragoza, Spain purpose, we analyzed the incidence of IEs and the Han criteria.13 Severity of IE was graded their impact on adherence to antineoplastic treat- according to the National Cancer Institute ment and with OS through modifications made to Common Toxicity Criteria for adverse events prescheduled protocols. (version 5·0).14 In addition, those infections 2 journals.sagepub.com/home/tah L Vilorio-Marqués, C Castañón Fernández et al. causing severe clinical impairment leading to using the Kaplan–Meier method and the log-rank treatment withdrawal were categorized as grade test. A landmark analysis of 6 months was per- 4. According to the Spanish Myelodysplastic formed to determine the impact of receiving less Syndromes Group (GESMD) guidelines, pri- than four cycles. A multivariable Cox model was mary prophylaxis with fluoroquinolones (FQs), performed to evaluate variables related to sur- antifungals, or another antimicrobial is not vival, including all variables with p value below advised.15 For the purpose of this study, however, 0.1 in the univariable comparisons and consider- all antimicrobials administered as prophylaxis ing only the first infection for each patient as a were recorded. time-dependent covariable. In this model, hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated. Outcomes The primary outcome was OS. Secondary end- This study conforms to the Strengthening the points were modifications to the prescheduled Reporting of Observational Studies in Epide­ treatment due to infection during cycles 1–4. The miology (STROBE) statement.16 A checklist of following events were considered modifications: the STROBE statement for cohort studies is dose reductions, dose delays (i.e. interval ⩾35 days shown in Supplementary Table 1. between consecutive cycles), and treatment with- drawals. Investigators had to indicate if such changes were consequence of IE. Other secondary Results endpoints were incidence and characteristics of IEs, hospitalization, red blood cell (RBC) transfu- Baseline characteristics of the study population sions, and factors associated with infection. Four hundred and twelve patients from 21 aca- demic and 2 non-academic centers participating in the RESMD between 21 February 2005 and Statistical analysis 18 January 2021 were analyzed. Median age was Baseline demographics and clinical variables were 73 (65–78) years. According to the WHO criteria, summarized as median [interquartile range 325 (79%) patients had MDS, 61 (15%) AML, (IQR)] or frequency (proportion) as appropriate. and 26 (6%) CMML. The most frequent MDS The rate of infection was calculated as the total diagnostic category was MDS with excess of number of IEs per patient-years of follow-up. For blasts (263 patients, 81%). Within AML, 15 each cycle, cumulative incidence of infection patients presented with 30% or more BM blasts. (CII) was calculated from the first day of cycle, A detailed description of baseline characteristics with death as a competing event. in the global population and separated by diag- nostic category is provided in Table 1 and Within the first four and six cycles, baseline data, Supplementary Tables 2 and 3. type of HMA, and prophylaxis with FQs were compared between cycles with and without infec- IPSS-R at the beginning of HMA treatment was tion using the Chi-square, Fisher’s or Wilcoxon’s low in 6 (2%) cases (Table 1). The reasons for tests as appropriate. The occurrence of IEs was initiating HMA treatment in these patients were studied using a multivariable Cox model which platelet counts below 30 × 109/l in five patients included those variables with a p value below 0.1 and grade 2–3 BM fibrosis according to the WHO in the univariable analysis. The relationship criteria in one patient. The median survival for between infection and transfusion was assessed these six patients was 11.9 months (0.7–20). by modeling the number of packed RBCs trans- fused according to infection and baseline hemo- Twelve CMML-2 were included. In the remain- globin level at the beginning of each cycle. ing 14 CMML patients, criteria for HMA treat- ment were percentage of BM blasts >5% in the OS was calculated from the day of diagnosis and presence of thrombocytopenia <30 × 109/l or from the beginning of HMA treatment until the anemia with transfusional dependence. The date of final follow-up. The probability of survival median time from diagnosis to the beginning of and differences between groups were estimated HMA treatment was 34 days (16–92). journals.sagepub.com/home/tah 3 Therapeutic Advances in Hematology Volume 13 Table 1. Baseline patients characteristics (N = 412). Table 1. (Continued) N or median % or range N or median % or range Age 73 65–78 Poor 21 34 Sex Failurea 1 2 Male 239 58 IPSS-R risk category Female 173 42 Good 6 2 Therapy related 73 18 Intermediate 74 23 ECOG High 238 73 0–1 248 81 NA 7 2 2 59 19 Hemoglobin (g/dl) 9.1 8.2–10.2 Percentage of bone marrow blasts Hb <9 g/dl 212 51 Global 10 6–16 ANC (×109/l) 1 0.5–2.3 AML 25 21–30 ANC <0.5 × 109/l 116 28 WHO diagnosis Platelets (×109/l) 53 28–102 AML 61 15 AML, acute myeloid leukemia; ANC, absolute neutrophil count; CMML, chronic myelomonocytic leukemia; ECOG, MDS Eastern Cooperative Oncology Group; Hb, hemoglobin; IPSS-R, International Prognostic Score System–Revised; MDS-U 10 2 MDS-EB, myelodysplastic syndrome with excess of blasts; MDS-MD, myelodysplastic syndrome with multilineage MDS (RS)/MDS-MD 52 13 dysplasia; MDS-RS, myelodysplastic syndrome with ring sideroblasts; MDS-U, myelodysplastic syndrome with MDS-EB 263 64 unilineage dysplasia; WHO, World Health Organization. aFailure: no metaphases were obtained. CMML 26 6 Cytogenetic risk Treatment MDS Overall, 4521 cycles of HMA were delivered to 412 patients. Azacitidine was the selected HMA Favorable 133 41 in 387 cases (94%), corresponding to a total of 4375 cycles. The drug was administered for Intermediate 60 18 7 days in 79% of cycles (3470/4375) and for Poor 125 38 5 days in 21% (905/4375) of cycles. Failurea 7 2 The median number of cycles was 6 (4–13), inde- pendently of HMA selected or WHO diagnosis CMML (Supplementary Table 3). One hundred and one Favorable 16 62 patients (24%) received less than four cycles of HMA, and 167 (41%) received less than six. Intermediate 3 11 Poor 7 27 FQ prophylaxis was prescribed in 33% of the patients (130 MDS, 30 AML, and 8 CMML). AML Patients with AML, adverse cytogenetics, or lower ANC received prophylaxis more fre- Intermediate 39 64 quently at the beginning of first HMA cycle (Continued) (Table 2). Regarding antifungal prophylaxis, 34 4 journals.sagepub.com/home/tah L Vilorio-Marqués, C Castañón Fernández et al. patients (8% of the whole population) received Table 2. Univariable comparisons of patients receiving or not antifungal prophylaxis with fluconazole (13 fluoroquinolone (FQ) prophylaxis. patients), itraconazole (2 patients), posaconazole FQ prophylaxis No FQ prophylaxis p (13 patients), voriconazole (2 patients), and non- specified (4 patients). Age (years) 73 (65–80) 73 (66–78) 0.9 Diagnostic category Overall Survival MDS 100/325 (31%) 225/325 (69%) 0.02 Median follow-up from diagnosis and from the beginning of HMA was 17 (9–34) and 12.5 (7– AML 30/61 (49%) 31/61 (51%) 24) months, respectively. AML patients showed CMML 8/26 (31%) 18/26 (69%) the lowest median OS, with 10.8 months (7.5– 15.6) compared with 15.3 (14–17.6) and 20.3 ANC* (×109/l) 0.65 (0.37–1.4) 1.3 (0.6–2.7) <0.001 (13.6–30) months in MDS and CMML patients, respectively (Supplementary Table 3). Hemoglobin (g/dl) 9.1 (8.2–10.2) 9.1 (8.2–10.3) 0.6 Platelets (×109/l) 56 (33–06) 51 (27–101) 0.3 There were 311 deaths. Infection was the main cause of death in 55 (18%) patients. Twenty-five Cytogenetics (45%) of these deaths occurred in the first three cycles, 18 (32%) between cycles four and six, Adverse 62/153 (41%) 91/153 (59%) 0.021 and 12 (22%) after the sixth cycle. Other causes Non-adverse 76/258 (29%) 182/258 (71%) of death were progression, hemorrhage, and toxicity secondary to subsequent treatments in AML, acute myeloid leukemia; ANC, absolute neutrophil count; CMML, chronic 202 (64%), 8 (3%), and 46 (15%) patients, myelomonocytic leukemia; FQ, fluoroquinolone; MDS, myelodysplastic syndrome. *Peripheral cell counts were obtained at the beginning of the first HMA treatment. respectively. Considering ANC at the beginning of each cycle, a significant association between ANC and using FQ prophylaxis was also observed. Median ANC was 0·5 × 109/l To evaluate the impact of infections on OS, we (0.2–1.2) in those cycles in which FQs were used compared with 1.2 × 109/l (0.6–2.3) first explored in univariable analyses the associa- in those in which they were not used, p < 0.001. tion of other well-known prognostic factors with survival9,17,18 in our population (Table 3). Eastern In the multivariable analysis considering infection Cooperative Oncology Group (ECOG) above as a time-dependent covariate, predictive factors one (HR = 1.3 [95% CI = 0.99–1.9], p = 0.054), for lower survival were BM blasts above 30% more than 30% BM blasts (HR = 2.3 [95% (HR = 2.13 [95% CI = 1.14–3.96], p = 0.01), CI = 1.34], p = 0.003), unfavorable cytogenetics unfavorable cytogenetics (HR = 1.70 [95% (HR = 1.86 [95% CI = 1.49–2.3], p < 0.0001), CI = 1.30–2.24], p < 0.001), platelet count below hemoglobin level below 9 g/dl (HR = 1.25 [95% 50 × 109/l (HR = 1.69 [95% CI = 1.3–2.2], CI = 1.004–1.6], p = 0.045), and platelet count p < 0.001), and any infection during the first four below 50 × 109/l (HR = 1.49 [95% CI = 1.2–1.9], cycles (HR = 1.43 [95% CI = 1.09–1.88], p = 0.01) p < 0.001) were associated with lower survival (Table 3). Infection during the first four cycles of (Figure 1). Any infection during the first four HMA treatment consistently increased the risk of cycles of HMA treatment was also associated with death in all the diagnostic categories in subgroup lower survival (HR = 1.7 [95% CI = 1.4–2.2], analyses (Supplementary Table 5). Owing to the p < 0.0001; Figure 2). Age, BM blasts above low number of patients in CMML and AML, 20%, ANC <0.5 or 0.8 × 109/l, or FQ prophy- however, it only remained statistically significant laxis did not significantly influence OS (Table 3 in the MDS population. and Supplementary Figure 1). Because modifications in the management of In the landmark analysis for those patients sur- infections derived from recommendations pub- viving 6 months or more, there were no signifi- lished in 201119 could have impacted the final cant differences between patients receiving more outcome of patients, these analysis were repeated or less than four cycles of therapy (HR = 1.01 in the cohort of patients treated after that [95% CI = 0.66–1.56], p = 0.95, Supplementary year. Out of 412 patients, 379 (92%) received Figure 2). their first cycle of therapy after 2011. In the journals.sagepub.com/home/tah 5 Therapeutic Advances in Hematology Volume 13 Table 3. Univariable and multivariable analyses for overall survival. Univariable Multivariable Median OS (days) p OR [95% CI] p Age ⩾75 441 0.85 <75 452 ECOG 0–1 468 0.054 ⩾2 362 Bone marrow blasts (%) 2.13 [1.14–3.96] 0.01 <30 459 0.003 ⩾30 211 Bone marrow blasts (%) <20 468 0.17 ⩾20 333 Cytogenetic 1.7 [1.30–2.24] <0.001 Good or intermediate 592 <0.0001 Unfavorable 354 Hb ⩾9 g/dl 496 0.045 <9 g/dl 366 ANC >0.8 g/l 441 0.85 ⩽0.8 g/l 453 0.83 >0.5 g/l 459 ⩽0.5 g/l 441 Platelets 1.69 [1.3–2.2] <0.001 ⩾50 g/l 538 <0.001 <50 g/l 373 Infection in first four cycles 1.43 [1.09–1.88] 0.01 No 534 <0.0001 Yes 342 Fluoroquinolone prophylaxis Global ANC <0.5 × 109/l AML FQ yes 424 434 346 FQ no 476 452 304 HR 1.2 1.08 0.89 [95% CI] [0.95–1.5] [0.68–1.73] [0.95–1.5] p 0.7 0.73 0.13 AML, acute myeloid leukemia; ANC, absolute neutrophil counts; CI, confidence interval; CMML, chronic myelomonocytic leukemia; ECOG, Eastern Cooperative Oncology Group; FQ, fluoroquinolone; Hb, hemoglobin; HR, hazard ratios; MDS, myelodysplastic syndrome; OS, overall survival; WHO, World Health Organization. multivariable Cox model, any infection during 33 months (27-NA) OS of the seven patients the first four cycles remained predictive for lower treated in non-academic centers was not worse survival (Supplementary Table 6). Finally, the compared with the OS of the whole population. 6 journals.sagepub.com/home/tah L Vilorio-Marqués, C Castañón Fernández et al. Figure 1. Survival analysis according to (a) percentage of bone marrow blasts, (b) Eastern Cooperative Oncology Group (ECOG) performance status, (c) cytogenetic category, (d) hemoglobin level above or below 9 g/dl, and (e) platelet count above or below 50 × 109/l. Incidence of IEs period, comprising cycles 1–3, was characterized Five hundred and twelve IEs (483 under HMA by a CII of at least 20%; the intermediate period treatment and 29 after HMA were stopped) were (cycles 4–6), in which CII decreased to 10–15%; recorded. CII followed a temporal pattern, high- finally, the late period (beyond the sixth cycle) lighting three periods with different incidence was the one with the lowest CII. Within each and epidemiological features (Table 4); the early period, the ratio of grade 4 infections relative to journals.sagepub.com/home/tah 7 Therapeutic Advances in Hematology Volume 13 Figure 2. Survival analysis according to occurrence of infection during the first four cycles of hypomethylating treatment. One patient without information regarding infections in the first two cycles was excluded. Univariate analysis (log-rank test) showed significant differences between patients having an infection during the first four cycles or not (p < 0.0001). total number of infections ranged from 10% to fungal infections were uncommon, with 17 infec- 20%. These differences were accompanied by a tions among 483 IEs. Three patients developed significative rise in the median hemoglobin level five invasive fungal episodes during HMA treat- and platelet count, but not in the absolute neutro- ment in cycles 1 (two patients) and 2 (one phil count (ANC). CII did not change after patient). In one patient, galactomannan antigen excluding patients experiencing any dose reduc- remained positive until death. Of note, baseline tion (Supplementary Table 7). neutrophil counts at the beginning of HMA in these three patients were 0.01, 1, and 0.02 × 109/l, Collectively, documented infections were the most respectively. None of them received antifungal frequent category followed by fever of unknown prophylaxis. Similarly, none of the patients who origin, blood stream, viral, and fungal infections developed other type of fungal infections received (Supplementary Table 8). Within the sites of infec- prophylaxis at the beginning of cycle, except one tion, the respiratory system was the most prevalent. who was receiving posaconazole and developed It must be noted that no microorganisms were oral candidiasis. Additional descriptions of cate- identified in 141/148 (97%) infections involving gory of infections, sites, and identified microor- the respiratory system (Supplementary Table 9). ganisms are provided in the Supplementary Material. Considering blood, urine, respiratory secretions, and tissue exudates, 109 microorganisms were identified, 102 of them being bacteria. Gram- Impact of infections on healthcare resources negative bacteria were the most prevalent bacte- There were 320 hospitalizations during the study ria, with 64 isolates (28 of them Escherichia coli). period involving 201 patients. Infections were the cause of 313 (98%) hospitalizations. Median Among viral infections, Herpes virus was docu- ANC count at the time of hospitalization for mented in 11 cases (2% of the total IEs). Finally, infection was 0·55 × 109/l (0.11–1.7). Other 8 journals.sagepub.com/home/tah L Vilorio-Marqués, C Castañón Fernández et al. Table 4. Total number and cumulative incidence of infection in each cycle. Cycle number Treatment period Early (cycles 1–3) Intermediate (cycles 4–6) Late (>sixth cycle) 1 2 3 4 5 6 >6 Number of infectious events 124 88 65 45 35 29 97 Cumulative incidence of 31 23 20 15 13 13 1–2 infection Grade 4 infections, %a (N) 15 (18/124) 12 (11/88) 17 (11/65) 10 (12/45) 14 (5/35) 33 (9/29) 12 (12/97) p Hb (g/dl) 9.3 (8.3–10.3) 10 (8.8–11.8) <0.001 ANC (×109/l) 0.9 (0.4–2.1) 1.1 (0.5–2.2) 0.09 Platelets (×109/l) 63 (30–127) 106 (45–181) <0.001 ANC, absolute neutrophil count; Hb, hemoglobin. Lower row: peripheral blood counts at the beginning of cycle. Rate of grade 4 infections and infections leading to suspension of HMA treatment. p indicates p value of difference in these values. aRelated to number of infections in each cycle. reasons for hospitalization were hemorrhage (five because 4/167 (2%) and 6/213 (2.8%) patients patients), clinical deterioration and platelet with and without IEs experienced dose reduc- refractoriness (one patient), and relapse (one tions (p = 1). patient). Median hospital stay was 9 (5–13) days. Clinical deterioration secondary to infection Patients with infections during the first four cycles prompted treatment withdrawal in 15 patients required more RBC transfusions within each (3.6%) from cycle 1 to 3. In addition, treatment cycle than those without them (8 [3–16] versus 5 withdrawal occurred in another eight patients [1–12], p = 0.002). The number of RBC transfu- during cycles 4 and 5. sions was correlated with both hemoglobin (coef- ficient = −0.83 [95% CI = −0.91 to –0.74], p < 0.001) and infection (coefficient = 1.43 [95% Impact of infections on length of treatment CI = 1.10–1.77], p < 0.001). Median number of cycles in patients with any infection in the first four was significantly lower Finally, 31/92 (34%) patients with any IE during compared with non-infected patients (5 [3–8] the early period developed IEs in the next period versus 8 [5–16], p < 0.001). Among 101 patients compared with 28/152 (19%) patients without receiving less than four cycles, infection was the early IEs (p = 0.01). Furthermore, among 19 cause of death or treatment withdrawal in 40 blood stream infections occurring in the interme- (40%). Cytogenetic and WHO categories, per- diate period, a previous IE was identified in 14. centage of BM blasts, hemoglobin, ANC, or platelet count were not associated with receiving less than four cycles. On the opposite, 23 (39%) Impact of infections on adherence to patients with baseline ECOG ⩾2 received less preplanned antineoplastic treatment than four cycles compared with 59 (24%) patients When considering the first four cycles, 95/167 with ECOG <2 (p = 0.02). (57%) patients with IEs experienced a delay in the beginning of the next cycle, compared with 64/213 (39%) in patients without any infection Infections and response to HMA treatment (p = 0.001). In contrast, IEs were not correlated The best response to HMAs was evaluated in 412 with dose reductions in the following cycles, patients, 202 of them (49%) being defined as journals.sagepub.com/home/tah 9 Therapeutic Advances in Hematology Volume 13 responders. During the first four cycles, IEs were category remained significant after excluding the most common in non-responders [119/219 (55%) nonavailable category (data not shown). versus 84/202 (42%), p = 0.002]. Karyotype, WHO diagnosis, or percentage of BM blasts were not associated with response. Discussion In this multicenter study, we have analyzed the incidence and consequences of IEs in patients Factors related to infection during the first four undergoing treatment with HMAs. We have cycles of HMA found that the incidence of IEs was higher In univariable comparisons, ⩾20% BM blasts, than what was reported in early clinical trials20,21 unfavorable karyotype, and lower ANC were sig- and had a profoundly negative impact on nificantly associated with developing IEs, whereas outcomes. higher hemoglobin and platelet count were asso- ciated with a lower rate of infection (Table 5). Our data contradict early clinical trials, which The use of prophylactic FQ when baseline ANC suggested that HMAs were safe in terms of infec- was <0.5 × 109/l was associated with a lower risk tious toxicity. Indeed, the incidence of febrile of infection [78/225 (35%) infections without FQ neutropenia in the MDS-00120 and AML-0013,21 compared with 44/180 (24%) on FQ, p = 0.03]. trial was lower in the azacitidine arm compared with the intensive chemotherapy or low-dose cyt- When the univariable analysis was repeated in each arabine arms. The incidence of pneumonia in diagnostic category, the association of infection patients receiving azacitidine was double com- with hemoglobin, cytogenetics, and BM blasts pared with those receiving only supportive care, remained significant, with a 5% blast cutoff in however.3,20,21 Moreover, infectious toxicity was MDS. Lower ANC remained significant in AML higher in patients randomized to receive decit- and in MDS when it was analyzed considering not abine than in those receiving supportive care22 or receiving FQ prophylaxis. Owing to the low num- cytarabine.23,24 This excess of toxicity was attrib- bers of patients diagnosed with CMML (N = 26), uted to the greater length of HMA treatment. As no significant associations between baseline char- infections occurred predominantly during the ini- acteristics and infection were observed except with tial HMA cycles, however,25 this increased risk of ANC (Supplementary Tables 11–13). infection should not be attributed exclusively to differences in treatment exposure. In a multivariable analysis performed in the whole population, BM blasts above 20% We show that IEs had a multidimensional impact (HR = 1.57 [95% CI = 1.19–2], p < 0.001) and that ultimately conditioned long-term outcome. unfavorable cytogenetics (HR = 1.7 [95% The negative effects of IEs included reduction in CI = 1.35–2], p = 0.001) were associated with chemotherapy dose intensity and response rate as higher risk of infection. On the opposite, hemo- noticed by others,26 premature treatment with- globin level >9 g/dl (HR = 0.65 [95% CI = 0.51– drawal, and increased consumption of healthcare 0.82], p < 0.001) and higher platelet count resources. The ultimate consequence of IEs was a (HR = 0.997 [95% CI = 0.996–0.998], p = 0.01) 40% increased risk of death. protected from infection (Table 5). Inclusion of BM blasts and hemoglobin as continuous varia- Overall, the risk for infection was closely related bles yielded similar results (HR = 1.02 [95% to the severity of the underlying disease. Low CI = 1.008–1.027], p < 0.001) and HR (0.81 hematopoietic reserve, high disease burden in [95% CI = 0.77–0.86], p < 0.001), respectively. terms of BM blasts and poor prognostic cytoge- Neither ANC nor FQ were individually associ- netics made patients more vulnerable to infec- ated with infection. The absence of FQ prophy- tion. Thus, there was a paradox in that those laxis when ANC where below 0.5 × 109/l increased patients with the greatest need of an appropriate the risk of infection (HR = 1.6 [95% CI = 1.12– dose intensity were also more likely to be under- 2.34], p = 0.01), however. treated because of their higher risk of infection. The same results were obtained when these anal- Our results may have practical implications. First, yses were repeated considering the first six cycles once HMA treatment is indicated, the decision to (Supplementary Table 14). Similarly, cytogenetic begin with the first cycle should not be delayed, as 10 journals.sagepub.com/home/tah L Vilorio-Marqués, C Castañón Fernández et al. Table 5. Univariable and multivariable analyses of prognostic factors for infectious episode in the first four cycles (N = 412 patients, 308 infectious events). Univariable analysis Multivariable analysis Infection No infection p OR [95% CI] p Age (median, IQR) 77 (69–784) 77 (69–78) 0.28 Sex, N (%) Male 176/835 (21) 659/835 (79) 0.82 Female 132/608 (22) 476/608 (78) ⩾20% BM blasts Yes 65/209 (31) 144/209 (69) <0.001 1.57a (1.19–2.01) <0.001 No 239/1222 (20) 983/1222 (80) Cytogenetic risk Good/intermediate 155/900 (17) 745/900 (83) <0.0001 1.7 (1.35–2.14) 0.001 Unfavorable 146/514 (28) 368/514 (72) NA 7/29 (24) 22/29 (76) Hemoglobin (g/dl) 9 (8.2–9.7) 9.5 (8.5–10.6) <0.0001 0.65 (0.51–0.82)b <0.001 Platelet count (×109/l) 53 (25–109) 76 (34–143) <0.0001 0.997 (0.996–0.998) 0.01 IPSS-R (MDS patients) <3.5 1/12 (8) 11/12 (92) 0.37 3.5–4.5 45/265 (17) 220/265 (83) >4.5 174/829 (21) 655/829 (79) NA 6/27 (22) 21/27 (78) Type of HMA Azacitidine 288/1352 (21) 1064/1352 (79) 0.98 Decitabine 20/91 (20) 71/91 (106) ANC 0.66 (0.24–1.8) 1.00 (0.49–2.18) <0.0001 0.98 (0.95–1.01) 0.3 ANC <0.5 × 109/l Without FQ 78/225 (35) 147/225 (65) 0.03 1.62 (1.12–2.34) 0.01 With FQ 44/180 (24) 136/180 (76) AML, acute myeloid leukemia; ANC, absolute neutrophil counts; BM, bone marrow; CMML, chronic myelomonocytic leukemia; FQ, fluoroquinolone; Hb, hemoglobin; HMA, hypomethylating agent; IPSS-R, International Prognostic Score System–Revised; MDS, myelodysplastic syndrome; WHO, World Health Organization. aCutoff value of 20%. bCutoff value of 9 g/dl. journals.sagepub.com/home/tah 11 Therapeutic Advances in Hematology Volume 13 the risk of infection increases with the severity of exceptionally lead to hospitalization. In contrast, cytopenias. Second, FQ prophylaxis seems to be we have shown that infections and hospitalization justified in severe neutropenic patients in whom it were significantly associated. The need for recov- reduces the risk of bacterial infection, apparently ery after hospitalization could have been the rea- without increasing antibiotic resistance. This son explaining the delay in the beginning of the information is relevant, as in the AZA-MDS-001 next cycle. Another limitation of the study is the trial, 28% patients received prophylaxis, but infor- lack of molecular information, which could have mation about its efficacy is not available. Moreover, helped to better categorize the risk of the underly- in AML, where HMAs are used in combination ing disease. Despite this, the accuracy of current with venetoclax and severe and prolonged neutro- classifications and prognostic scoring systems penia is expected, prophylaxis might be critical. allowed us to identify a subgroup of patients – Third, confronting previous reports,27 the low those with adverse cytogenetics – in whom the incidence of invasive fungal infections found in biology of the disease confers a higher risk of this study do not support the use of wide-spec- infection. Finally, although this is the largest trum azole prophylaxis, although we cannot rule study on infections undertaken so far, AML out its potential role in severe neutropenic patients. and CMML are under-represented, thus preclud- Finally, strategies aimed at preventing infection ing definite conclusions about risk factors for should be intensified in poor prognostic categories infection other than neutropenia within these and during the first cycles of treatment in order to groups. avoid cycle delays, thus maximizing the efficacy of antineoplastic treatment.6 In conclusion, this study shows that infectious toxicity secondary to HMAs is common and has a Several aspects ensure the reliability of our profound and negative impact on the outcome of results. First, the long recruitment period and patients. This excess of toxicity contributes to multicenter nature (23 hospitals across a coun- explain the undertreatment and the lower than try) guarantee the external validity of the study expected survival observed outside clinical trials. and minimize selection bias. The confirmation of In order to ensure that HMAs are used in a safely the validity of classic prognostic factors9,28 and and efficiently way, it is imperative to develop the survival rates similar to other series1,2,29 con- strategies for preventing and controlling infec- firm the representativity of the sample. Second, tious toxicity. we have confirmed that changes in the manage- ment of infections resulting from the implemen- Declarations tation of recent guidelines19 did not modify the final results. Third, all IEs that occurred through- Ethics approval and consent to participate out the treatment were reported irrespective of The study was approved by the Regional Ethics their severity, thus avoiding the loss of informa- Committee for Clinical Investigation of the tion that occurs when these patients receive Principado de Asturias (Oviedo, Spain, ref assistance in centers other than in those in which 204/17) and the Institutional Review Board of the HMAs were prescribed.30 Fourth, we have Spanish Myelodysplastic Syndromes Group excluded patients who received HMA after (GESMD). Patients were included in the registry chemotherapy, in whom infectious toxicity is sig- after informed consent in accordance with the nificantly higher.31 Declaration of Helsinki. The main limitations of the study are related to its Consent for publication retrospective nature and the potential bias when Not applicable. interpreting the consequences of infection on dose reductions and cycle delays. Dose reduc- Author contributions tions occurred in a similar rate in patients with or Laura Vilorio-Marqués: Data curation; Formal without pre-existing infection, however, suggest- analysis; Investigation; Project administration; ing homogeneous criteria in the management of Writing – review & editing. cytopenias. Regarding the distinction between delays secondary to infection and those related to Christelle Castañón Fernández: Data cura- cytopenias, it must be noted that cytopenias itself tion; Investigation; Writing – review & editing. 12 journals.sagepub.com/home/tah L Vilorio-Marqués, C Castañón Fernández et al. Elvira Mora: Data curation; Investigation; Teresa Bernal: Conceptualization; Formal Writing – review & editing. analysis; Investigation; Methodology; Super­ vision; Validation; Writing – original draft; Lorena Gutiérrez: Data curation; Investigation; Writing – review & editing. Writing – review & editing. Beatriz Rey Bua: Data curation; Investigation; Acknowledgements Writing – review & editing. The authors are thankful to the following Maria José Jiménez Lorenzo: Data curation; GESMD investigators who participated in this Investigation; Writing – review & editing. study: Marina Díaz Beya: Data curation; Investigation; Carlos Aguilar, Hematology Department, Writing – review & editing. Hospital General Santa Bárbara Soria. Luis Benlloch, Spanish Group of Myelodysplastic Miriam Vara Pampliega: Data curation; Syndromes, Grupo Español de Síndromes mielo- Investigation; Writing – review & editing. displásicos. Nicolás Díaz Varela, Hematology Antonieta Molero: Data curation; Investigation; Department, Hospital Universitario Santiago de Writing – review & editing. Compostela. Cristián Escolano, Hematology Department, Hospital Universitario de Getafe. Joaquín Sánchez-García: Data curation; Ángela Gil Pérez, Hematology Department, Investigation; Writing – review & editing. Hospital Universitario de Guadalajara. Marta Marisa Calabuig: Data curation; Investigation; Gómez Núñez, Hematology Department, Writing – review & editing. Hospital Universitario Parc Taulí Hospital. Ana Lerma Verdejo, Hematology Department, Maria Teresa Cedena: Data curation; Investi­ Hospital Nuestra Señora del Prado. Carolina gation; Writing – review & editing. Muñoz, Hematology Department, Hospital Tzu Chen-Liang: Data curation; Investigation; Infanta Leonor. M. Ángeles Pérez Sáenz, Writing – review & editing. Fundación Jiménez Díaz. Andoni Urrutia, Johana Alejandra Díaz Santa: Data curation; Hematology Department, Clínica Universitaria Investigation; Writing – review & editing. Navarra. Irene Padilla: Data curation; Investigation; Funding Writing – review & editing. The authors received no financial support for the Francisca Hernández: Data curation; research, authorship, and/or publication of this Investigation; Writing – review & editing. article. Rosana Díez: Data curation; Investigation; Competing interests Writing – review & editing. The authors declared the following potential con- Pedro Asensi: Data curation; Investigation; flict of interest with respect to the research, Writing – review & editing. authorship, and/or publication of this article: T.B. has received support for attending meetings Blanca Xicoy: Investigation; Methodology; and/or travel from Jazz Pharmaceutical, honoraria Visualization; Writing – original draft; Writing – from Jazz Pharmaceutical, BMS, and Pfizer. D.V. review & editing. has received honoraria from Celgene/BMS, Guillermo Sanz: Methodology; Visualization; Amgen, Novartis, Jazz Pharmaceuticals, and Writing – original draft; Writing – review & Pfizer and support for attending meetings and/or editing. travel from Amgen, BMS/Celgene, and Jazz. M.D.-C. reports honoraria and membership on David Valcárcel: Conceptualization; Method­ entity’s Board of directors or advisory committees ology; Visualization; Writing – original draft; from Novartis, BMS, and Takeda. Dr G.S. has Writing – review & editing. received personal fees from AbbVie, Amgen, and María Diez-Campelo: Conceptualization; Astellas and has received research funding from Methodology; Visualization; Writing – original Celgene/BMS Janssen-Cilag, Novartis, Roche, draft; Writing – review & editing. and Takeda. journals.sagepub.com/home/tah 13 Therapeutic Advances in Hematology Volume 13 Availability of data and materials for myelodysplastic syndromes. Blood 2012; 120: All data used in the analysis are anonymized. 2454–2465. 10. Such E, Germing U, Malcovati L, et al. ORCID iD Development and validation of a prognostic Teresa Bernal https://orcid.org/0000-0002- scoring system for patients with chronic 2338-513X myelomonocytic leukemia. Blood 2013; 121: 3005–3015. 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