Infection-related mortality and infection control practices in childhood acute myeloid leukemia in a limited resource setting: Experience with the Indonesian national protocol

Background: In resource-limited settings, addressing infections remains a substantial
challenge in the management of children with Acute Myeloid Leukemia (AML). In Indonesia,
infection-related mortality (IRM) is thought to be high compared to high-income countries.
However, there has been no previous study of infection profile and IRM in Indonesian patients
with AML.
Objective: This study aimed to describe infections and IRM in children with AML treated
according to the Indonesian National AML protocol and to describe the implementation of
infection control practices in resource-limited settings.
Methods: This retrospective observational study used secondary data from the medical
records of pediatric patients with AML treated with the National Protocol at Dr. Sardjito
Hospital, Yogyakarta, Indonesia, from April 2012 to September 2018. Essential patient
characteristics, time of IRM, and cause of death were recorded, and infection control practices
were observed. Data were analyzed using descriptive statistics.
Results: 113 patients with AML were treated with the National protocol, and 83 met the
inclusion criteria. Infections occurred in 69 (83%) patients with a total of 123 episodes (mean
1.8/patient). Death was seen in 48 (58%) patients, with 19 (23%) IRM. The majority of
infections were in the gastrointestinal tract (n = 51, 30.5%), sepsis (n = 29, 17%), and
respiratory tract (n = 28, 17%). Infections mostly occurred during the first induction (41%).
There were 90 (73%) episodes of clinically documented infection and 33 (27%) episodes of
microbiologically documented infection. The positivity rate of blood cultures was only 27%.
The majority of bacteria detected were gram-negative (n = 25, 69%), and among them were
Klebsiella pneumonia (19%) and Escherichia coli (19%). Candida albicans was detected in 1
(2%) culture. Suboptimal infection prevention and control were found in the clinical practice.
Conclusion: Infections and infection-related mortality in children with AML treated using the
National protocol were frequent, mainly occurring during the first induction phase. Compliance
with infection prevention and control measures needs improvement. Urgent attention is
required for better supportive care, including isolation rooms, antibiotics, and antifungals. The
predominance of Gram-negative bacterial infections highlights the necessity for further
research into effective prophylaxis. Enhanced healthcare and nursing professional vigilance
and tailored antibiotic strategies are vital. Improving compliance and ensuring adequate
supportive care resources are essential, emphasizing nursing’s pivotal role. Further research
is crucial to drive advancements in infection control strategies.