Etoposide treatment in secondary hemophagocytic syndrome: impact on healthcare-associated infections and survival

Thibault Dupont; Michael Darmon; Eric Mariotte; Virginie Lemiale; Jehane Fadlallah; Adrien Mirouse; Lara Zafrani; Elie Azoulay; Sandrine Valade

doi:10.1186/s13613-022-01075-9

Etoposide treatment in secondary hemophagocytic syndrome: impact on healthcare-associated infections and survival

Ann Intensive Care. 2022 Oct 28;12(1):101. doi: 10.1186/s13613-022-01075-9.

Authors

Thibault Dupont^{1

2}, Michael Darmon^{3

4

5}, Eric Mariotte^{3

4}, Virginie Lemiale^{3

4}, Jehane Fadlallah^{4

5

6}, Adrien Mirouse^{3

4}, Lara Zafrani^{3

4}, Elie Azoulay^{3

4}, Sandrine Valade^{3

4}

Affiliations

¹ Assistance Publique-Hôpitaux de Paris (APHP), Medical Intensive Care Unit, Saint-Louis University Hospital, 1 Avenue Claude Vellefaux, 75010, Paris, France. zicmud@gmail.com.
² Université de Paris, Paris, France. zicmud@gmail.com.
³ Assistance Publique-Hôpitaux de Paris (APHP), Medical Intensive Care Unit, Saint-Louis University Hospital, 1 Avenue Claude Vellefaux, 75010, Paris, France.
⁴ Université de Paris, Paris, France.
⁵ UMR 1153, Center of Epidemiology and Biostatistics, ECSTRA Team and Clinical Epidemiology, Sorbonne Paris Cité, CRESS, INSERM, Paris, France.
⁶ Assistance Publique-Hôpitaux de Paris (APHP), Immunology Department, Saint-Louis University Hospital, Paris, France.

Abstract

Background: Etoposide remains the cornerstone of symptomatic management of critically ill patients with secondary hemophagocytic syndrome (sHS). Risk of healthcare-associated infections (HAIs) in this setting with etoposide has never been assessed. We sought to evaluate the association between etoposide administration, HAIs occurrence and survival in critically ill adult patients with sHS. In this retrospective single-center study conducted in a university hospital ICU between January 2007 and March 2020, all consecutive patients with sHS were included. HAIs were defined as any microbiologically documented infection throughout ICU stay. Competing risk survival analysis was performed to determine factors associated with HAIs. Propensity score-based overlap weighting was performed to adjust for factors associated with etoposide use.

Results: 168 patients with a median age of 49 [38, 59] were included. Forty-three (25.6%) patients presented with at least 1 microbiologically documented HAI throughout ICU stay. After adjustment, cumulative incidence of HAI was higher in patients receiving etoposide (p = 0.007), while survival was unaffected by etoposide status (p = 0.824). By multivariable analysis, etoposide treatment was associated with a higher incidence of HAIs (sHR 3.75 [1.05, 6.67]), whereas no association with survival (sHR 0.53 [0.20, 1.98]) was found. Other factors associated with increased mortality after adjustment included age, immunodepression, male sex, SOFA score > 13, and occurrence of HAI.

Conclusions: In patients with sHS, etoposide treatment is independently associated with increased occurrence of HAIs, whereas no association with survival was found. Intensivists should be aware of increased infectious risk, to promptly detect and treat infections in this specific setting. Studies to assess benefits from prophylactic anti-infectious agents in this setting are warranted and the lack of benefit of etoposide on survival needs to be interpreted cautiously.

Keywords: Etoposide; Hemophagocytic syndrome; Hospital acquired infections.