Risk Factors for Sepsis in Pediatric All During Induction Chemotherapy-Induced Neutropenia: A Single-Center Retrospective Study

Objective: To identify clinical factors associated with sepsis during induction chemotherapy–induced neutropenia (CIN) in children with acute lymphoblastic leukemia (ALL). Methods: This single-center retrospective study included 292 children with ALL who received induction chemotherapy between January 2019 and July 2024. Candidate variables were extracted within 24 hours after the first onset of CIN. Sepsis was defined using the pediatric Sequential Organ Failure Assessment (pSOFA). Univariable Cox regression, collinearity assessment using variance inflation factor (VIF), and multivariable Cox regression analyses were performed to identify risk factors associated with time to sepsis. Kaplan-Meier analyses were used to illustrate sepsis-free survival according to key factors. Results: Sepsis occurred in 48/292 (16.4%) patients. In multivariable analysis, oral mucosal status (HR=1.336, 95% CI: 1.061– 1.681, P=0.014), C-reactive protein to albumin ratio (CAR) (HR=1.407, 95% CI: 1.088– 1.806, P=0.050), red cell distribution width (RDW) (HR=1.126, 95% CI: 1.028– 1.233, P=0.011), and procalcitonin (PCT) (HR=1.017, 95% CI: 1.002– 1.036, P=0.043) were independently associated with sepsis risk. Kaplan-Meier analyses showed significantly different sepsis-free survival across strata of these factors (all P< 0.05). Conclusion: Oral mucosal status, CAR, RDW, and PCT were independently associated with sepsis risk during CIN in children with ALL. These findings may inform early risk assessment and warrant confirmation in larger, multicenter cohorts. Keywords: acute lymphoblastic leukemia, children, sepsis, chemotherapy-induced neutropenia, risk factors, cox regression analysis