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Avilés-Robles MJ, Reyes-López A. Economic implications of step-down outpatient management for fever and neutropenia episodes in pediatric cancer patients: a cost minimization analysis. BMC Health Serv Res 2024; 24:981. [PMID: 39182090 PMCID: PMC11344398 DOI: 10.1186/s12913-024-11442-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/14/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND The management of febrile neutropenia (FN) in pediatric cancer patients has traditionally been conducted in a hospital setting. However, recent evidence has indicated that outpatient management of FN can be equally effective compared to inpatient care. Based on this evidence, we conducted a cost-minimization analysis (CMA) specifically focused on pediatric cancer patients in Mexico. METHODS A piggy-back study was conducted during the execution of a non-inferiority clinical trial that compared outpatient treatment to inpatient treatment for FN in children with cancer. A CMA was performed from a societal perspective using patient-level data. In the previous study, we observed that step-down oral outpatient management of low-risk FN was as safe and effective as inpatient intravenous management. Direct and indirect costs were collected prospectively. The costs were adjusted for inflation and converted to US dollars, with values standardized to July 2022 costs. Statistical analysis using bootstrap methods was employed to obtain robust estimations for decision-making within the Mexican public health care system. RESULTS A total of 117 FN episodes were analyzed, with 60 in the outpatient group and 57 in the inpatient group; however, complete cost data were available for only 115 FN episodes. The analysis revealed an average savings of $1,087 per FN episode managed on an outpatient basis, representing a significant 92% reduction in total cost per FN episode compared to inpatient treatment. Length of hospital stay and inpatient consultations emerged as the primary cost drivers within the inpatient care group. CONCLUSION This CMA demonstrates that the step-down outpatient management approach is cost-saving when compared to inpatient management of FN in pediatric cancer patients. The mean difference observed between the treatment groups provides support for decision-making within the public health care system, as outpatient management of FN allows for substantial cost savings without compromising patient health.
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Affiliation(s)
- Martha J Avilés-Robles
- Infectious Diseases Department, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Alfonso Reyes-López
- Center of Economics and Social Studies in Health, Hospital Infantil de México Federico Gómez, Mexico City, Mexico.
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Zhao W, Zhou Y, Wang X, Yang P, Huang C, Ma X, Su Y, Zhang R. Mecapegfilgrastim for prophylaxis of febrile neutropenia in children and adolescents with rhabdomyosarcoma or Ewing sarcoma: a prospective, single-arm, pilot study. BMC Cancer 2024; 24:1013. [PMID: 39148050 PMCID: PMC11325604 DOI: 10.1186/s12885-024-12766-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 08/06/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND The chemotherapy regimens recommended for both rhabdomyosarcoma (RMS) and Ewing sarcoma (ES) patients are myelosuppressive and can reduce the absolute neutrophil count (ANC) and subsequently increase the risk of febrile neutropenia (FN). However, only a few studies have focused on the efficacy and safety of granulocyte-colony stimulating factor (G-CSF) drugs in pediatric and adolescent patients with RMS and ES. Our objective was to investigate the efficacy and safety of mecapegfilgrastim, a biosimilar of pegfilgrastim, in prophylaxis of FN for pediatric and adolescent patients with RMS or ES. METHODS In this single-arm, single-center, prospective study, pediatric and adolescent patients with RMS or ES were enrolled to receive either VAC (vincristine, cyclophosphamide, dactinomycin) regimen or VDC (vincristine, cyclophosphamide, doxorubicin) regimen in a 3-week cycle, followed by treatment with mecapegfilgrastim (100 μg/kg, maximum 6 mg) given at 24 h after completing chemotherapy. The primary endpoint was the incidence rate of FN. Secondary endpoints included the incidence rate of grade 4 neutropenia, duration of ANC ≤ 0.5 × 109/L, incidence rate of chemotherapy delay or reduction, use of antibiotics, and safety profile. RESULTS In total, 2 of the 30 (6.7%, 95% CI: 0.82-22.07) patients experienced FN after the first cycle of chemotherapy. Eight (26.7%, 95% CI: 12.28-45.89) patients experienced grade 4 neutropenia after receiving prophylactic mecapegfilgrastim. Eight patients experienced ANC ≤ 0.5 × 109/L with a median duration of 4.5 days; among them, 6 patients reached the lowest point of their ANC level on day 7, and 5 of them recovered by day 10. No dose reductions, delays, or discontinuation of chemotherapy was reported. Twenty-one (70.0%) patients received antibiotics during the treatment period. No patient experienced FN in the 0-5 years and the 13-18 years groups, and 2 patients experienced FN in the 6-12 years group. Two patients, 6 patients, and no patient experienced grade 4 neutropenia in the 0-5 years, 6-12 years, and 13-18 years groups, respectively. CONCLUSION Mecapegfilgrastim showed acceptable efficacy and safety profile in pediatric and adolescent patients with RMS or ES. Further randomized studies with large sample size are warranted. TRIAL REGISTRATION This clinical trial was registered at Chictr.org.cn (No.ChiCTR1900022249). Registered on March 31, 2019.
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Affiliation(s)
- Wen Zhao
- Medical Oncology Department, Pediatric Oncology CenterNational Center for Children's HealthKey Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Yuchen Zhou
- Medical Oncology Department, Pediatric Oncology CenterNational Center for Children's HealthKey Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Xisi Wang
- Medical Oncology Department, Pediatric Oncology CenterNational Center for Children's HealthKey Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Peiyi Yang
- Medical Oncology Department, Pediatric Oncology CenterNational Center for Children's HealthKey Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Cheng Huang
- Medical Oncology Department, Pediatric Oncology CenterNational Center for Children's HealthKey Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Xiaoli Ma
- Medical Oncology Department, Pediatric Oncology CenterNational Center for Children's HealthKey Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Yan Su
- Medical Oncology Department, Pediatric Oncology CenterNational Center for Children's HealthKey Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China.
| | - Rui Zhang
- Hematology CenterNational Center for Children's HealthKey Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China.
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3
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Gomez B, Almarza F, López-Almaraz R, Quintana O, Mintegi S. Characteristics of oncology patients with fever and invasive bacterial infections diagnosed. Acta Paediatr 2024. [PMID: 39091245 DOI: 10.1111/apa.17369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 07/15/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024]
Abstract
AIM To describe the characteristics of febrile oncology patients seen in the Paediatric Emergency Department and microbiological characteristics of the invasive bacterial infections (IBIs) diagnosed. METHODS We conducted a prospective observational study of febrile oncology patients seen between 2016 and 2022. We divided haematologic cancers by the aggressiveness of the chemotherapy received at the time. RESULTS We included 418 episodes (272 haematologic cancers, 146 solid tumours). The median duration of fever was 2 h (interquartile range: 1-3) and 97.6% of patients were well-appearing on arrival. We diagnosed 61 IBIs (14.6%), including six episodes of bacterial sepsis. One other episode was coded as sepsis without microbiological confirmation, yielding seven episodes overall (1.7%). Rates of IBI and sepsis were higher among patients with high-risk haematologic cancers than those with low-risk haematologic cancers or solid tumours (22.9%, 5.4% and 10.3%, p < 0.01; 3.4%, 0% and 0.7%, p = 0.06, respectively). Leading causes were S. epidermidis (42.6%) and E. coli (14.7%). Gram-positive bacteria caused 67.2% of non-septic IBIs and 50% of septic episodes. CONCLUSION Most febrile oncology patients are well-appearing and present with a very short history of fever. Prevalence of IBI and sepsis and the main disease-causing bacteria differ by cancer type and the presence of sepsis.
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Affiliation(s)
- Borja Gomez
- Pediatric Emergency Department, Hospital Universitario Cruces, Biocruces Bizkaia Health Research Institute, Barakaldo, Basque Country, Spain
| | - Fernando Almarza
- Department of Pediatrics, Hospital Universitario Cruces, Barakaldo, Basque Country, Spain
| | - Ricardo López-Almaraz
- Department of Pediatrics, Pediatric Hemato-Oncology Unit, Hospital Universitario Cruces, Biocruces Bizkaia Health Research Institute, Barakaldo, Basque Country, Spain
| | - Oriol Quintana
- Department of Pediatrics, Hospital Universitario Cruces, Barakaldo, Basque Country, Spain
| | - Santiago Mintegi
- Pediatric Emergency Department, Hospital Universitario Cruces, Biocruces Bizkaia Health Research Institute, Barakaldo, Basque Country, Spain
- Department of Pediatrics, Universidad del Pais Vasco, Bilbao, Basque Country, Spain
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Kobayashi R, Sano H, Matsushima S, Hori D, Yanagi M, Suzuki D. Analysis of bacteremia at first-line antibiotic treatment for febrile neutropenia in children and adolescents: A retrospective, single-center analysis. J Infect Chemother 2024; 30:642-645. [PMID: 38301745 DOI: 10.1016/j.jiac.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/18/2024] [Accepted: 01/27/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Control of bacterial and fungal infections is critical to improving outcomes in hematological neoplastic diseases of children and adolescents. In this study, a retrospective analysis of our previous studies on febrile neutropenia was performed to investigate bacteremia. PROCEDURE From August 2008 to December 2023, five antibiotic studies were performed for febrile and neutropenic pediatric patients who had been treated with chemotherapy, immunosuppressive therapy, or had received stem cell transplantation in the pediatric unit at Sapporo Hokuyu Hospital. The rate of positive blood culture, detected bacteria, and susceptibility of several types of antibiotics in febrile episodes were investigated. RESULTS Blood culture was positive in 133 of 1604 febrile episodes of 329 patients. Detected bacteria were Gram-positive cocci (61.2 %), Gram-negative bacilli (27.6 %), Gram-negative cocci (0.7 %), and Gram-positive bacilli (10.4 %). The incidence of bacteremia over time showed a decreasing trend with each passing year. In particular, the incidence of bacteremia was around 10 % in 2008-2013, whereas it was often below 5 % after 2020; this decrease was statistically significant. Although almost all detected bacteria and their susceptibilities to antibiotics (piperacillin/tazobactam, meropenem, ceftazidime, and cefozopran) did not change over time, all Escherichia coli detected after 2014 were extended-spectrum β-lactamase-producing bacteria.
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Affiliation(s)
- Ryoji Kobayashi
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, Japan.
| | - Hirozumi Sano
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, Japan
| | - Satoru Matsushima
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, Japan
| | - Daiki Hori
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, Japan
| | - Masato Yanagi
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, Japan
| | - Daisuke Suzuki
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, Japan
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Gumus DD, Demir OO, Aykac K, Hazirolan G, Avci H, Ceyhan M, Cengiz AB, Ozsurekci Y. Gram-negative bacteremia, the risk factors, and outcome in children. Diagn Microbiol Infect Dis 2024; 109:116324. [PMID: 38733752 DOI: 10.1016/j.diagmicrobio.2024.116324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 11/17/2023] [Accepted: 04/22/2024] [Indexed: 05/13/2024]
Abstract
We aimed to determine the epidemiology and resistance patterns of Gram-negative bacteria, the risk factors and outcome of bloodstream infection (BSI). In all, 412 episodes in children who were hospitalized with the diagnosis of bacteremia were analyzed. The most common microorganisms were Klebsiella spp. (43.9%), Escherichia coli (13.5 %) and Acinetobacter spp. (10.6 %). Among isolates, 41.2 % were multidrug-resistant, 13.5 % were extensively drug-resistant and 0.4 % were pan-drug-resistant. Carbapenem resistance was revealed in 27.6 % of isolates. Carbapenem and colistin resistance increased over the years. The most common risk factors were the presence of a central-venous catheter and pediatric intensive care unit admission. Clinical response and infection-related mortality were significantly different in cases infected with carbapenem-resistant gram-negative (CRGN) vs carbapenem-susceptible gram-negative bacteria. The increase in multi-resistant Klebsiella spp. seems to be the biggest obstacles in fight against nosocomial infections. The increasing number of CRGN infections over the years affects both the clinical response and mortality rate of BSI.
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Affiliation(s)
- Dilan Demir Gumus
- Hacettepe University Faculty of Medicine, Department of Pediatrics, Ankara, Turkey
| | - Osman Oguz Demir
- Hacettepe University Faculty of Medicine, Department of Pediatrics, Ankara, Turkey; The Hospital for Sick Children Research Institute, Cell Biology Research Program, Toronto, ON, Canada
| | - Kubra Aykac
- Hacettepe University Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Gulsen Hazirolan
- Hacettepe University Faculty of Medicine, Department of Microbiology, Ankara, Turkey
| | - Hanife Avci
- Hacettepe University Faculty of Medicine, Department of Biostatistics, Ankara, Turkey
| | - Mehmet Ceyhan
- Hacettepe University Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Ali Bulent Cengiz
- Hacettepe University Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Yasemin Ozsurekci
- Hacettepe University Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey.
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Clément L, Hélène D, Maud M, Chrystelle D, Constance B, Fréderic M, France R, Pilar GHM, José-Miguel TD, Blandine R. Safety of empirical antibiotic therapy discontinuing for fever of unknown origin during high-risk neutropenia in children. J Infect 2024; 88:106171. [PMID: 38697268 DOI: 10.1016/j.jinf.2024.106171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND ECIL-2021 recommends discontinuing empirical antibiotic therapy (EAT) in febrile-neutropenic children after 72 h of treatment and at least 24-48 h of apyrexia in the case of fever of unknown origin (FUO). These guidelines are rarely applied to high-risk children's neutropenia. MATERIAL AND METHODS We retrospectively included all consecutive FUO episodes occurring during profound neutropenia ≥ 10 days in children in our institution. We evaluated the safety of EAT discontinuation in patients for whom the ECIL guidelines were followed compared to those for whom they didn't. We used a combined criterion of mortality and intensive care unit admission at 30 days. We identified risk factors for recurrent fever after EAT discontinuation. RESULTS Fifty-one FUO episodes occurred in 37 patients. EAT discontinuation followed ECIL guidelines in 19 (37 %) episodes. No deaths and-or transfers in ICU occurred in the ECIL group. The duration of EAT was shorter by nine days in the group following ECIL guidelines (p < 0.001). We observed 14 (27 %) episodes of recurrent fever. Mucositis was significantly associated with recurrent fever (p < 0.01). CONCLUSION EAT discontinuation seems feasible and safe in FUO during prolonged febrile neutropenia in children. However, mucosal lesions should prompt thorough surveillance due to the risk of recurrent fever.
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Affiliation(s)
- Lemaigre Clément
- CHU Poitiers, Service de Maladies Infectieuses et Tropicales, Poitiers, France; Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France
| | - Deutch Hélène
- Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | - Meligne Maud
- Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | - Dupraz Chrystelle
- Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | | | - Millot Fréderic
- Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | - Roblot France
- CHU Poitiers, Service de Maladies Infectieuses et Tropicales, Poitiers, France; Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; INSERM U1070, Poitiers, France
| | - Gallego-Hernanz Maria Pilar
- Service d'Oncologie Hématologique Et Thérapie Cellulaire, INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, 86021 Poitiers Cedex, France
| | - Torregrosa-Diaz José-Miguel
- Service d'Oncologie Hématologique Et Thérapie Cellulaire, INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, 86021 Poitiers Cedex, France
| | - Rammaert Blandine
- CHU Poitiers, Service de Maladies Infectieuses et Tropicales, Poitiers, France; Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; INSERM U1070, Poitiers, France.
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Zhang W, Nie W, Li B, Wang H. Ultrasonography is an effective method for evaluating hepatosplenic fungal infections in pediatric onco-hematological patients. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024. [PMID: 38761012 DOI: 10.1002/jcu.23730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE This prospective study assessed the value of ultrasonography (US) in the evaluation of hepatosplenic fungal infections (HSFI). METHODS Thirty-two pediatric participants with confirmed onco-hematological diseases and HSFI were included. Lesions in the liver and/or spleen were detected by US, magnetic resonance imaging (MRI), or computed tomography (CT). RESULTS Of the participants, 11 (34%) had confirmed HSFI, while 21 (66%) had highly suspected HSFI. The US, CT, MRI, and fungal blood cultures demonstrated positive results in 31, 19, 25, and 7 patients, respectively. US had a significantly higher detection rate than CT, MRI, and fungal blood cultures (p < 0.05). The "bull's eye" phenomenon was a distinctive US feature of HSFI. Follow-up examinations indicated that after a mean of 7.7 (1-15) months, liver and/or spleen lesions disappeared in five patients. The lesion was significantly smaller in 10 patients. Residual calcifications were detected in 15 patients. Two patients died. CONCLUSION Conclusively, the US may substitute for tissue biopsy, other imaging modalities, or fungal blood culture for the confirmation of HSFI, and may guide better antifungal treatment, thus achieving better outcomes.
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Affiliation(s)
- Wenhua Zhang
- Department of Medical Ultrasound, The First Affiliated Hospital of Shandong First Medical University (Shandong Provincial Qianfoshan Hospital), Jinan, Shandong, China
| | - Wei Nie
- Department of Medical Ultrasound, The First Affiliated Hospital of Shandong First Medical University (Shandong Provincial Qianfoshan Hospital), Jinan, Shandong, China
| | - Bin Li
- Department of Medical Ultrasound, The First Affiliated Hospital of Shandong First Medical University (Shandong Provincial Qianfoshan Hospital), Jinan, Shandong, China
| | - Hui Wang
- Department of Special Examination, The Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
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Barnbrock A, Salmanton-García J, Lankes F, Bochennek K, Schöning S, Lehrnbecher T. No Impact of Dietary Restrictions on the Risk for Infection in Pediatric Patients With Cancer: A Monocenter Analysis. JCO Oncol Pract 2024; 20:503-508. [PMID: 38261984 DOI: 10.1200/op.23.00553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/06/2023] [Accepted: 10/31/2023] [Indexed: 01/25/2024] Open
Abstract
PURPOSE Prophylactic anti-infective strategies are used in patients with cancer to decrease the risk for infection. Dietary restrictions do not allow raw vegetables and fresh fruits to limit the introduction of potentially harmful pathogens in the gastrointestinal tract, but the efficacy is unclear. PATIENTS AND METHODS In this study analyzing the impact of the dietary restrictions on infectious complications, all children treated between April 2014 and March 2018 for ALL and AML or non-Hodgkin lymphoma (NHL) were included. Dietary restrictions were standard until March 2016, but were stopped in April 2016. Patients with dietary restrictions (treated April 2014-March 2016) and patients not advised for dietary restrictions (treated April 2016-March 2018) were compared regarding infectious complications, including bloodstream infection, pneumonia, diarrhea, and fever of unknown origin (FUO). RESULTS Eighty-six patients (25 female; 62 ALL; nine AML, 15 NHL) experienced 223 infections. The 46 patients with dietary restrictions and the 40 patients without food restrictions did not significantly differ regarding the number of infections per patient, bloodstream infections, pneumonia, diarrhea, FUO, admission to intensive care, and death. CONCLUSION Our data suggest that dietary restrictions do not affect the risk for infectious complications. Therefore, the indication of dietary restrictions should be reconsidered in pediatric patients with cancer.
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Affiliation(s)
- Anke Barnbrock
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Jon Salmanton-García
- Faculty of Medicine and University Hospital Cologne, Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Excellence Center for Medical Mycology, University of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Franziska Lankes
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Konrad Bochennek
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Stefan Schöning
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Thomas Lehrnbecher
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
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Karadaş N, Özdemir HH, Yilmaz Y, Göktepe ŞÖ, Ece D, Karapinar DY. Primary Mold-Active Antifungal Prophylaxis Decreases the Need for Chest Computed Tomography Scans in Patients with Acute Lymphoblastic Leukemia. Indian J Hematol Blood Transfus 2024; 40:196-203. [PMID: 38708155 PMCID: PMC11065793 DOI: 10.1007/s12288-023-01697-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 09/03/2023] [Indexed: 05/07/2024] Open
Abstract
Current guidelines recommend computed tomography (cCT) scans of the chest in children with leukemia following 96 h of the onset of idiopathic neutropenia to eliminate pulmonary invasive fungal infections (IFIs). However, cCT exposes some children who are at a very high risk of developing secondary cancers to radiation. We aimed to determine the effect of antifungal prophylaxis (AFP) with voriconazole (VCZ) on the need for cCT scans in children with acute lymphoblastic leukemia (ALL) to eliminate pulmonary IFIs during chemotherapy. We retrospectively screened all patients' data from their electronic charts. Children who were diagnosed as having ALL before February 2013 and did (AFP group) or did not (NoP group) receive AFP were divided into two groups and compared regarding cCT scans and relapse-mortality rates. Ninety-six children were diagnosed before February 2013 and did not receive primary AFP and 146 children were administered VCZ following a diagnosis of ALL. There were no significant demographic differences between the groups. A total of 128 cCTs had been required in 62 children in the NoP group, compared with 64 cCTs in 52 children in the AFP group. The percentage of the patients who had required at least one chest CT scan and the mean number of cCT scans in the NoP group were significantly higher compared with the AFP group. Proven-probable IFIs and relapse-mortality rates were higher in the NoP group compared with the AFP group. Mold-active AFP revealed a significant decrease in the need for cCT scans in children with ALL.
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Affiliation(s)
- Nihal Karadaş
- Ege University Faculty of Medicine, Children’s Hospital, Department of Pediatric Hematology, IZMIR, Bornova, Turkey
| | - Hamiyet Hekimci Özdemir
- Ege University Faculty of Medicine, Children’s Hospital, Department of Pediatric Hematology, IZMIR, Bornova, Turkey
| | - Yeşer Yilmaz
- Katip Çelebi University Medical School, IZMIR, Bornova, Turkey
| | - Şebnem Önen Göktepe
- Ege University Faculty of Medicine, Children’s Hospital, Department of Pediatric Hematology, IZMIR, Bornova, Turkey
| | - Dilek Ece
- Ege University Faculty of Medicine, Children’s Hospital, Department of Pediatric Hematology, IZMIR, Bornova, Turkey
| | - Deniz Yilmaz Karapinar
- Ege University Faculty of Medicine, Children’s Hospital, Department of Pediatric Hematology, IZMIR, Bornova, Turkey
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Dupuis LL, Fisher BT, Sugalski AJ, Grimes A, Nuño M, Ramakrishnan S, Beauchemin MP, Robinson PD, Santesso N, Walsh A, Wrightson AR, Yu L, Parsons SK, Sung L. Clinical practice guideline-inconsistent management of fever and neutropenia in pediatric oncology: A Children's Oncology Group study. Pediatr Blood Cancer 2024; 71:e30880. [PMID: 38291716 PMCID: PMC10937100 DOI: 10.1002/pbc.30880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/29/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND The primary objective was to measure the proportion of episodes where care delivery was inconsistent with selected recommendations of a clinical practice guideline (CPG) on fever and neutropenia (FN) management. The influence of site size on CPG-inconsistent care delivery, and association between patient outcomes and CPG-inconsistent care were described. METHODS This retrospective, multicenter study included patients less than 21 years old with cancer who were at high risk of poor FN outcomes and were previously enrolled to a Children's Oncology Group (COG) study at participating National Cancer Institute Community Oncology Research Program (NCORP) institutions from January 2014 through December 2015. Patients were randomly selected for chart review by participating sites from a COG-generated list. Care delivered in each episode was adjudicated (CPG-consistent or CPG-inconsistent) against each of five selected recommendations. RESULTS A total of 107 patients from 22 sites, representing 157 FN episodes, were included. The most common CPG-inconsistent care delivered was omission of pulmonary computerized tomography in patients with persistent FN (60.3%). Of 74 episodes where assessment of four (episodes without persistent FN) or five (episodes with persistent FN) recommendations was possible, CPG-inconsistent care was delivered with respect to at least one recommendation in 63 (85%) episodes. Site size was not associated with CPG-inconsistent care delivery. No statistically significant association between CPG-inconsistent care and fever recurrence was observed. CONCLUSIONS In this cohort of pediatric patients at high risk of poor FN outcomes, CPG-inconsistent care was common. Opportunities to optimize resource stewardship by boosting supportive care CPG implementation are highlighted.
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Affiliation(s)
- LL Dupuis
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Department of Pharmacy, The Hospital for Sick Children; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - BT Fisher
- The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, US
| | - AJ Sugalski
- University of Texas Health Science Center San Antonio, San Antonio, Texas, US
| | - A Grimes
- University of Texas Health Science Center San Antonio, San Antonio, Texas, US
| | - M Nuño
- Children’s Oncology Group, Monrovia, USA
| | | | - MP Beauchemin
- Columbia University Irving Medical Center, New York, USA
| | - PD Robinson
- Pediatric Oncology Group of Ontario, Toronto, Canada
| | - N Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - A Walsh
- Center for Cancer and Blood Disorders, Phoenix Children’s Hospital, Phoenix, USA. University of Arizona, Phoenix, USA
| | - AR Wrightson
- Clinical Research Nurse Coordinator, Nemours Center for Cancer and Blood Disorders, Wilmington, USA
| | - L Yu
- LSUHSC/Children’s Hospital, New Orleans, USA
| | - SK Parsons
- Institute for Clinical Research and Health Policy Studies and Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA
| | - L Sung
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
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11
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Mareković I, Vujnović T, Radanović J, Herljević Z, Kuliš T, Pavlović M, Mucavac L, Dejanović-Bekić S, Bilić E. Bloodstream Infections in Pediatric Oncology Patients: Bacterial Pathogen Distribution and Antimicrobial Susceptibility at the University Hospital Centre Zagreb, Croatia-A 5-Year Analysis. J Pediatr Hematol Oncol 2024; 46:e156-e163. [PMID: 38237002 DOI: 10.1097/mph.0000000000002809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024]
Abstract
The epidemiology of bacterial pathogens causing bloodstream infections (BSIs) in pediatric hematology/oncology patients is changing and resistance to antimicrobial agents is globally spread. We retrospectively assessed demographic, clinical, and microbiologic data of BSIs during a 5-year period at a pediatric hematology/oncology unit from January 1, 2017, to December 31, 2021, at the University Hospital Centre Zagreb, Zagreb, Croatia. In 66 pediatric patients with malignancies, 93 BSI episodes were registered and 97 bacterial isolates were cultured. The Gram-positive versus Gram-negative ratio was 67 (69.1%) versus 30 (30.9%). Coagulase-negative staphylococci (48; 49.6%) were the most frequent isolates, followed by Enterobacterales (17; 17.5%) and Staphylococcus aureus (6; 6.2%). Multidrug resistance isolates included extended spectrum β-lactamase producers (n=3). Resistance rates to piperacillin/tazobactam, cefepime, and meropenem in Gram-negative isolates were 15.4%, 14.3%, and 0.0%, respectively. Gram-positive bacteria are the most common cause of BSI in our patients. Resistance rates to piperacillin/tazobactam and cefepime in Gram-negative isolates make meropenem a better choice for empirical antimicrobial treatment. As national and hospital data may differ, the surveillance of pathogen distribution and antimicrobial susceptibility in pediatric hematology/oncology wards is necessary to adjust empirical treatment accordingly.
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Affiliation(s)
- Ivana Mareković
- Clinical Department of Clinical Microbiology, Infection and Prevention Control, University Hospital Centre Zagreb
- Department of Medical Microbiology and Parasitology, School of Medicine University of Zagreb
| | - Tajana Vujnović
- Department of Clinical Microbiology, Andrija Štampar Teaching Institute of Public Health
| | - Jasna Radanović
- Department of Microbiology, Institute of Public Health Zagreb County
| | - Zoran Herljević
- Clinical Department of Clinical Microbiology, Infection and Prevention Control, University Hospital Centre Zagreb
| | - Tomislav Kuliš
- Department of Urology, University Hospital Centre Zagreb
| | - Maja Pavlović
- Department of Pediatrics, Division of Hematology and Oncology, University Hospital Zagreb
| | - Lucija Mucavac
- Department of Pediatrics, Division of Hematology and Oncology, University Hospital Zagreb
| | - Sara Dejanović-Bekić
- Department of Pediatrics, Division of Hematology and Oncology, University Hospital Zagreb
| | - Ernest Bilić
- Department of Pediatrics, Division of Hematology and Oncology, University Hospital Zagreb
- Department of Pediatrics, School of Medicine University of Zagreb
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12
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Whitehurst DA, Friedman DL, Zhao Z, Sarma A, Snyder E, Dulek DE, Banerjee R, Kitko CL, Esbenshade AJ. A comprehensive assessment of the prolonged febrile neutropenia evaluation in pediatric oncology patients. Pediatr Blood Cancer 2024; 71:e30818. [PMID: 38110594 DOI: 10.1002/pbc.30818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/14/2023] [Accepted: 12/01/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Pediatric oncology patients with prolonged (≥96 hours) febrile neutropenia (absolute neutrophil count < 500/μL) often undergo an evaluation for invasive fungal disease (IFD) and other infections. Current literature suggests that beta-D-glucan (BDG), galactomannan, bronchoalveolar lavage (BAL), and computed tomography (CT) scans (sinus, chest, and abdomen/pelvis) may help determine a diagnosis in this population. METHODS In a retrospective cohort study of all cancer/stem cell transplant patients (diagnosed 2005-2019) from one pediatric hospital, all episodes with prolonged febrile neutropenia or IFD evaluations (defined as sending a fungal biomarker or performing a CT scan to assess for infection) were identified. RESULTS In total, 503 episodes met inclusion criteria and 64% underwent IFD evaluations. In total, 36.4% of episodes documented an infection after initiation of prolonged febrile evaluation, most commonly Clostridioides difficile colitis (6.4%) followed by a true bacterial bloodstream infection (BSI) (5.2%), proven/probable IFD (4.8%), and positive respiratory pathogen panel (3.6%). There was no difference in sinus CTs showing sinusitis (74% vs 63%, p = 0.46), whereas 32% of abdomen/pelvis CTs led to a non-IFD diagnosis, and 25% of chest CTs showed possible pneumonia. On chest CT, the positive predictive value (PPV) for IFD was 19% for nodules and 14% for tree and bud lesions. BDG had a PPV of 25% for IFD and GM 50%. BAL diagnosed IFD once and pneumocystis jirovecii pneumonia twice. CONCLUSIONS Chest CTs and abdomen/pelvis CTs provide clinically relevant information during the prolonged febrile neutropenia evaluation, whereas BDG, galactomannan, BAL, and sinus CTs have less certain utility.
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Affiliation(s)
| | - Debra L Friedman
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Pediatric Hematology-Oncology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Asha Sarma
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth Snyder
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel E Dulek
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- Division of Pediatric Infectious Diseases, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Ritu Banerjee
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- Division of Pediatric Infectious Diseases, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Carrie L Kitko
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Pediatric Hematology-Oncology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Adam J Esbenshade
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Pediatric Hematology-Oncology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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13
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Smeallie ET, Choi SW, Mody R, Guetterman TC, Nessle CN. "Better at home": Mixed methods report of intricacies in pediatric febrile neutropenia management. Cancer Med 2024; 13:e7106. [PMID: 38506249 PMCID: PMC10952020 DOI: 10.1002/cam4.7106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 02/02/2024] [Accepted: 03/02/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION Many febrile neutropenia (FN) episodes are low risk (LR) for severe outcomes and can safely receive less aggressive management and early hospital discharge. Validated risk tools are recommended by the Children's Oncology Group to identify LR FN episodes. However, the complex dynamics of early hospital discharge and burdens faced by caregivers associated with the FN episode have been inadequately described. METHODS An adapted quality-of-life (QoL) survey instrument was administered by a convergent mixed methods design; qualitative and quantitative data from two sources, the medical record and the mixed methods survey instrument, were independently analyzed prior to linkage and integration. Code book was informed by conceptual framework; open coding was used. Mixed methods analysis used joint display of results to determine meta-inferences. RESULTS Twenty-eight patient-caregiver dyads participated with a response rate of 87%. Of the 27 FN episodes, 51.8% (14/27) were LR and 40.7% (11/27) had an early hospital discharge. The LR and early hospital discharge groups had higher mean QoL scores comparatively. Meta-inferences are reciprocal influencers and expand the complex situation; FN negatively affects the entire family, and the benefits of hospital management were outweighed by risks and worsened symptoms, so an individualized approach to management and care at home was preferred. CONCLUSION Early discharge of LR FN episodes positively impacts QoL, yet risk-stratified management for FN is intricately complex. Optimal FN management should prioritize the patient's overall health; shared decision-making is recommended and can improve care delivery. These results should be confirmed in a larger, more heterogeneous population.
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Affiliation(s)
| | - Sung W. Choi
- Department of PediatricsUniversity of MichiganAnn ArborMichiganUSA
- Division of Pediatric Hematology OncologyUniversity of MichiganAnn ArborMichiganUSA
| | - Rajen Mody
- Department of PediatricsUniversity of MichiganAnn ArborMichiganUSA
- Division of Pediatric Hematology OncologyUniversity of MichiganAnn ArborMichiganUSA
| | - Timothy C. Guetterman
- Rogel Comprehensive Cancer CenterUniversity of MichiganAnn ArborMichiganUSA
- Department of Family Medicine, Mixed Methods ProgramUniversity of MichiganAnn ArborMichiganUSA
| | - Charles N. Nessle
- Department of PediatricsUniversity of MichiganAnn ArborMichiganUSA
- Division of Pediatric Hematology OncologyUniversity of MichiganAnn ArborMichiganUSA
- Fogarty International CenterNational Institute of HealthBethesdaMarylandUSA
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14
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Liberati C, Donà D, Maestri L, Petris MG, Barbieri E, Gallo E, Gallocchio J, Pierobon M, Calore E, Zin A, Brigadoi G, Mariani M, Mesini A, Saffioti C, Ugolotti E, Gregori D, Giaquinto C, Castagnola E, Biffi A. Application of the Weighted-Incidence Syndromic Combination Antibiogram (WISCA) to guide the empiric antibiotic treatment of febrile neutropenia in oncological paediatric patients: experience from two paediatric hospitals in Northern Italy. Ann Clin Microbiol Antimicrob 2024; 23:16. [PMID: 38360651 PMCID: PMC10870518 DOI: 10.1186/s12941-024-00673-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/30/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Guidelines about febrile neutropenia in paediatric patients are not homogeneous; the best empiric treatment of this condition should be driven by local epidemiology. The Weighted-Incidence Syndromic Combination Antibiogram (WISCA) addresses the need for disease-specific local susceptibility evidence that could guide empiric antibiotic prescriptions based on outcome estimates of treatment regimens obtained as a weighted average of pathogen susceptibilities. This study developed a WISCA model to inform empirical antibiotic regimen selection for febrile neutropenia (FN) episodes in onco-haematological paediatric patients treated at two Italian paediatric tertiary centres. METHODS We included blood cultures from patients with a bloodstream infection and neutropenia admitted to the Paediatric Haematology-Oncology wards in Padua and Genoa Hospitals from 2016 to 2021. WISCAs were developed by estimating the coverage of 20 antibiotics as monotherapy and of 21 combined regimens with a Bayesian probability distribution. RESULTS We collected 350 blood cultures, including 196 g-negative and 154 g-positive bacteria. Considering the most used antibiotic combinations, such as piperacillin-tazobactam plus amikacin, the median coverage for the pool of bacteria collected in the study was 78%. When adding a glycopeptide, the median coverage increased to 89%, while the replacement of piperacillin-tazobactam with meropenem did not provide benefits. The developed WISCAs showed that no monotherapy offered an adequate coverage rate for the identified pathogens. CONCLUSIONS The application of WISCA offers the possibility of maximizing the clinical utility of microbiological surveillance data derived from large hospitals to inform the choice of the best empiric treatment while contributing to spare broad-spectrum antibiotics.
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Affiliation(s)
- Cecilia Liberati
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padua, Padua, Italy
| | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padua, Padua, Italy.
| | - Linda Maestri
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padua, Padua, Italy
| | - Maria Grazia Petris
- Division of Paediatric Haematology, Oncology and Stem Cell Transplant, Department for Women's and Children's Health, University of Padua, Padua, Italy
| | - Elisa Barbieri
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padua, Padua, Italy
| | - Elisa Gallo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Jacopo Gallocchio
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Marta Pierobon
- Division of Paediatric Haematology, Oncology and Stem Cell Transplant, Department for Women's and Children's Health, University of Padua, Padua, Italy
| | - Elisabetta Calore
- Division of Paediatric Haematology, Oncology and Stem Cell Transplant, Department for Women's and Children's Health, University of Padua, Padua, Italy
| | - Annachiara Zin
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padua, Padua, Italy
| | - Giulia Brigadoi
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padua, Padua, Italy
| | - Marcello Mariani
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - Alessio Mesini
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - Carolina Saffioti
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - Elisabetta Ugolotti
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Carlo Giaquinto
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padua, Padua, Italy
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - Alessandra Biffi
- Division of Paediatric Haematology, Oncology and Stem Cell Transplant, Department for Women's and Children's Health, University of Padua, Padua, Italy
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15
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Sarquis T, Ibáñez C, De La Maza V, Valenzuela R, Zubieta M, Labraña Y, Gutiérrez V, Greppi C, Martínez D, Díaz P, Santolaya ME. Usefulness of Peripheral Blood Cultures in Children With Cancer and Episodes of Fever and Neutropenia. Pediatr Infect Dis J 2024; 43:160-164. [PMID: 38063512 DOI: 10.1097/inf.0000000000004168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
BACKGROUND The collection of blood cultures (BC) is key for guiding antimicrobial therapy in children with febrile neutropenia (FN), more than 90% have central venous catheters (CVC). There is no consensus on the need for peripheral BC over central BC in this population. The aim of this study was to determine the contribution of peripheral BC over central BC in the diagnosis of bloodstream infections in children with FN. METHODS Descriptive, retrospective study, episodes of FN recorded prospectively in 6 hospitals in Santiago, Chile, from 2016 to 2021. Central and peripheral BC were drawn upon admission. All episodes with at least one (+) BC were allocated to one of these groups: consistent (+) BC, inconsistent (+) BC, only CVC (+) BC and only peripheral (+) BC. The volume of the samples was recorded. RESULTS The analysis included 241 episodes of FN with at least one (+) BC. The median age was 7.2 years, 51% were female, 84% had hematological cancer and 98% had episodes of high-risk FN. Of a total of 241 episodes, 135 (56%) had consistent (+) BC, 13 (5%) had inconsistent (+) BC, 35 (15%) had only CVC (+) BC and 58 (24%) had only peripheral (+) BC. There were no significant differences in the volume of the samples between central and peripheral BC. CONCLUSIONS The proportion of bloodstream infections detected only through peripheral BC was 24%, higher than previously reported, not due to sample volume. We recommend obtaining peripheral as well CVC BC in children with FN.
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Affiliation(s)
- Teresita Sarquis
- Department of Pediatrics and Pediatric Surgery, Hospital Roberto del Rio, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Carolina Ibáñez
- Department of Pediatrics and Pediatric Surgery, Hospital Luis Calvo Mackenna, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Verónica De La Maza
- Department of Pediatrics and Pediatric Surgery, Hospital Luis Calvo Mackenna, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Romina Valenzuela
- Department of Pediatrics and Pediatric Surgery, Hospital Luis Calvo Mackenna, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Marcela Zubieta
- Departamento de Pediatría y Cirugía Infantil Sur, Hospital Dr. Exequiel González Cortés, Pediatría Sur, Santiago, Chile
- Committee of Infectious Diseases, National Child Program of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Yenis Labraña
- Committee of Infectious Diseases, National Child Program of Antineoplastic Drugs (PINDA), Santiago, Chile
- Hospital San Juan De Dios, Pediatrics, Santiago, Chile
| | - Valentina Gutiérrez
- Committee of Infectious Diseases, National Child Program of Antineoplastic Drugs (PINDA), Santiago, Chile
- Department of Pediatrics, Complejo Asistencial Doctor Sotero del Rio, Santiago, Chile
| | - Claudia Greppi
- Committee of Infectious Diseases, National Child Program of Antineoplastic Drugs (PINDA), Santiago, Chile
- Department of Pediatrics and Pediatric Surgery, Hospital Roberto del Rio, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Daniela Martínez
- Committee of Infectious Diseases, National Child Program of Antineoplastic Drugs (PINDA), Santiago, Chile
- Hospital San Borja Arriaran, Facultad de Medicina, Universidad de Chile
| | - Paulina Díaz
- Committee of Infectious Diseases, National Child Program of Antineoplastic Drugs (PINDA), Santiago, Chile
- Hospital Gustavo Fricke, Pediatrics, Viña del Mar, Chile
| | - María Elena Santolaya
- Department of Infectious Diseases, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
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16
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Gal Etzioni TR, Fainshtain N, Nitzan-Luques A, Goldstein G, Weinreb S, Temper V, Korem M, Averbuch D. Invasive Fungal Infections in Children with Acute Leukemia: Epidemiology, Risk Factors, and Outcome. Microorganisms 2024; 12:145. [PMID: 38257971 PMCID: PMC10820110 DOI: 10.3390/microorganisms12010145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Invasive fungal infections (IFI) cause morbidity and mortality in children with acute leukemia (AL). We retrospectively collected data on febrile neutropenic episodes (FNE) in AL children (2016-2021) and assessed factors associated with proven/probable IFI. Ninety-three children developed 339 FNE. Seventeen (18.3%) children developed 19 proven/probable IFI (11 yeast; eight molds). The proven/probable yeast IFI rate was 6/52 (11.5%) in children who belong to the high risk for IFI category (HR-IFI-AL: high-risk acute lymphocytic leukemia (ALL), acute myeloid leukemia, relapse); and 5/41 (12.2%) in the non-HR-IFI-AL category (standard/intermediate risk ALL). The proven/probable mold IFI rate was 7/52 (13.5%) in HR-IFI-AL children and 1/41 (2.4%) in the non-HR-IFI-AL category. In the multivariable analysis, underlying genetic syndrome, oral mucositis, and older age were significantly associated with proven/probable IFI, while a longer time since AL diagnosis was protective. Two of 13 (15.4%) HR-IFI-AL children died because of IFI. The elevated risks of proven/probable mold IFI and the associated mortality in HR-IFI-AL children, and high risk of invasive candidiasis in the non-HR-IFI-AL group, emphasize the need for the close monitoring of local epidemiology and the adjustment of practices accordingly.
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Affiliation(s)
- Tamar Ruth Gal Etzioni
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (T.R.G.E.); (N.F.); (A.N.-L.); (G.G.); (S.W.); (V.T.); (M.K.)
- Pediatric Division, Hadassah Medical Center, Jerusalem 91120, Israel
| | - Nurit Fainshtain
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (T.R.G.E.); (N.F.); (A.N.-L.); (G.G.); (S.W.); (V.T.); (M.K.)
- Pediatric Division, Hadassah Medical Center, Jerusalem 91120, Israel
| | - Adi Nitzan-Luques
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (T.R.G.E.); (N.F.); (A.N.-L.); (G.G.); (S.W.); (V.T.); (M.K.)
- Pediatric Division, Hadassah Medical Center, Jerusalem 91120, Israel
- The Dyna & Fala Weinstock Department of Pediatric Hematology Oncology, Hadassah Medical Center, Jerusalem 91120, Israel
| | - Gal Goldstein
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (T.R.G.E.); (N.F.); (A.N.-L.); (G.G.); (S.W.); (V.T.); (M.K.)
- Pediatric Division, Hadassah Medical Center, Jerusalem 91120, Israel
- The Dyna & Fala Weinstock Department of Pediatric Hematology Oncology, Hadassah Medical Center, Jerusalem 91120, Israel
| | - Sigal Weinreb
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (T.R.G.E.); (N.F.); (A.N.-L.); (G.G.); (S.W.); (V.T.); (M.K.)
- Pediatric Division, Hadassah Medical Center, Jerusalem 91120, Israel
- The Dyna & Fala Weinstock Department of Pediatric Hematology Oncology, Hadassah Medical Center, Jerusalem 91120, Israel
| | - Violeta Temper
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (T.R.G.E.); (N.F.); (A.N.-L.); (G.G.); (S.W.); (V.T.); (M.K.)
- Department of Microbiology and Infectious Diseases, Hadassah Medical Center, Jerusalem 91120, Israel
| | - Maya Korem
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (T.R.G.E.); (N.F.); (A.N.-L.); (G.G.); (S.W.); (V.T.); (M.K.)
- Department of Microbiology and Infectious Diseases, Hadassah Medical Center, Jerusalem 91120, Israel
| | - Dina Averbuch
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (T.R.G.E.); (N.F.); (A.N.-L.); (G.G.); (S.W.); (V.T.); (M.K.)
- Pediatric Division, Hadassah Medical Center, Jerusalem 91120, Israel
- Pediatric Infectious Diseases, Hadassah Medical Center, Jerusalem 91120, Israel
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17
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Weischendorff S, Rathe M, Petersen MJ, Weimann A, Enevold C, Nielsen CH, Als-Nielsen B, Nygaard U, Moser C, Müller K. Markers of intestinal mucositis to predict blood stream infections at the onset of fever during treatment for childhood acute leukemia. Leukemia 2024; 38:14-20. [PMID: 37919603 PMCID: PMC10776407 DOI: 10.1038/s41375-023-02077-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
Despite chemotherapy-induced intestinal mucositis being a main risk factor for blood stream infections (BSIs), no studies have investigated mucositis severity to predict BSI at fever onset during acute leukemia treatment. This study prospectively evaluated intestinal mucositis severity in 85 children with acute leukemia, representing 242 febrile episodes (122 with concurrent neutropenia) by measuring plasma levels of citrulline (reflecting enterocyte loss), regenerating islet-derived-protein 3α (REG3α, an intestinal antimicrobial peptide) and CCL20 (a mucosal immune regulatory chemokine) along with the general neutrophil chemo-attractants CXCL1 and CXCL8 at fever onset. BSI was documented in 14% of all febrile episodes and in 20% of the neutropenic febrile episodes. In age-, sex-, diagnosis- and neutrophil count-adjusted analyses, decreasing citrulline levels and increasing REG3α and CCL20 levels were independently associated with increased odds of BSI (OR = 1.6, 1.5 and 1.7 per halving/doubling, all p < 0.05). Additionally, higher CXCL1 and CXCL8 levels increased the odds of BSI (OR = 1.8 and 1.7 per doubling, all p < 0.0001). All three chemokines showed improved diagnostic accuracy compared to C-reactive protein and procalcitonin. These findings underline the importance of disrupted intestinal integrity as a main risk factor for BSI and suggest that objective markers for monitoring mucositis severity may help predicting BSI at fever onset.
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Affiliation(s)
- Sarah Weischendorff
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen, Denmark.
| | - Mathias Rathe
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Allan Weimann
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Christian Enevold
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen, Denmark
| | - Claus H Nielsen
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen, Denmark
| | - Bodil Als-Nielsen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Ulrikka Nygaard
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Müller
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Zhang L, Wang Y, Lin L, Yu Y, Lu S. Chinese multidisciplinary expert consensus on the management of adverse drug reactions associated with savolitinib. Ther Adv Med Oncol 2023; 15:17588359231216089. [PMID: 38145112 PMCID: PMC10748904 DOI: 10.1177/17588359231216089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/07/2023] [Indexed: 12/26/2023] Open
Abstract
Savolitinib is a highly selective mesenchymal-epithelial transition (MET) tyrosine kinase inhibitor (TKI). Based on its significant efficacy shown in clinical studies, savolitinib was conditionally approved for marketing in China on 22 June 2021, for the treatment of advanced non-small cell lung cancer (NSCLC) with MET 14 exon skipping mutation. Additionally, many studies showed that MET TKIs were equally effective in patients with advanced solid tumors with MET gene amplification or MET protein overexpression. Several relevant registered clinical studies are in progress. The most common adverse reactions (ARs) due to savolitinib administration are nausea, vomiting, peripheral edema, pyrexia, and hepatotoxicity. This consensus was developed through two rounds of extensive national surveys involving multidisciplinary experts in China, aiming to guide clinicians to prevent and treat various ARs scientifically, and improve the efficacy of the drug and the quality of life of patients.
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Affiliation(s)
- Li Zhang
- Department of Respiratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yongsheng Wang
- Department of Oncology, West China Hospital, Sichuan University, Chengdu, China
| | - Lizhu Lin
- Department of Oncology, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yongfeng Yu
- Department Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shun Lu
- Department Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
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19
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Zhu X, Zhang W, Zhang Y, Wang Y, Hu H, Li J, Zhou Y, Han T, Huang D. Pegfilgrastim on febrile neutropenia in pediatric and adolescent cancer patients: a systematic review and meta-analysis. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2023; 28:2172292. [PMID: 36719297 DOI: 10.1080/16078454.2023.2172292] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES There is no meta-analysis about the effects of pegfilgrastim on the occurrence of febrile neutropenia (FN) in pediatric/adolescent cancer patients. The study explored the efficacy of prophylactic pegfilgrastim in preventing FN in children/adolescents with cancer. METHODS PubMed, Embase, and the Cochrane Library were searched for studies published before April 7, 2020. The primary outcome was the rate of FN. Effect size (ES) and odds ratio (OR) with 95% confidence intervals (CIs) were used to evaluate the outcome. The ES represented the rate of FN, and the STATA 'metaprop' command was used to synthesize the rate. RESULTS Eight studies were included, comprising 167 patients and 550 courses of treatment. There was no difference between pegfilgrastim and filgrastim for the rate of FN in children receiving chemotherapy (OR = 0.68, 95% CI: 0.20-2.23, P = 0.520). In patients receiving pegfilgrastim, the rate of FN was 25.6% (95% CI: 14.9%-36.3%), the rate of grade 4 FN was 38.3% (95% CI: 19.2%-59.5%), the rate of severe neutropenia (SN) was 40.5% (95% CI: 35.1%-46.1%), and the rate of treatment delays due to FN was 4.8% (95% CI: 0.8%-11.3%). DISCUSSION The number of studies that could be included was small; therefore, a specific type of cancer or a specific treatment could be studied. Heterogeneity was high. CONCLUSION There was no difference between pegfilgrastim and filgrastim for the rate of FN. The use of pegfilgrastim was still associated with rates of FN, grade 4 FN, severe neutropenia, and treatment delays due to FN in pediatric cancer patients.
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Affiliation(s)
- Xia Zhu
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Weiling Zhang
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Yi Zhang
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Yizhuo Wang
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Huimin Hu
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Jing Li
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Yan Zhou
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Tao Han
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Dongsheng Huang
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
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20
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Patel PA, Teherani MF, Xiang Y, Bernardo V, Chandrakasan S, Goggin KP, Haight A, Horwitz E, Liang WH, Parikh SH, Schoettler ML, Spencer K, Stenger E, Watkins B, Williams KM, Leung K, Jaggi P, Qayed M. Short-Course Empiric Antibiotics in Children Undergoing Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:778.e1-778.e6. [PMID: 37739225 DOI: 10.1016/j.jtct.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/24/2023]
Abstract
Fever is common in children undergoing hematopoietic cell transplantation (HCT). Empiric antibiotic (EA) therapy is initiated and often continued until neutrophil engraftment. Prolonged antibiotic exposure reduces microbiome diversity and causes overgrowth of pathogenic organisms, leading to such complications as infections from antibiotic-resistant organisms and Clostridium difficile colitis. Shorter courses of EA therapy have been studied in adults undergoing HCT without significant safety concerns, but data in children are lacking. We instituted a single-center preintervention/ postintervention quality improvement (QI) project to assess the feasibility of short-course EA therapy for first fever in patients undergoing HCT. We aimed to reduce the median duration of broad-spectrum antibiotic use in eligible patients from 20 days in 2020 to 10 days in 2021. Patients were eligible for the intervention, limiting EAs to 7 days for first fever, if they were admitted for their first allogeneic HCT, were afebrile for >24 hours, had no infection requiring systemic treatment, and were hemodynamically stable. Outcome measures included days of EA therapy for first fever and total broad-spectrum antibiotic use during the period of hospitalization, defined as the time from the start of conditioning to 30 days after HCT or hospital discharge, whichever occurred first. Balancing measures included bloodstream infection (BSI), fever, and intensive care (ICU) admission within 3 days of stopping EA therapy. Project criteria were applied retrospectively to patients who underwent HCT in 2020 to construct a preintervention short-course-eligible cohort. During the intervention period, 41 patients underwent allogeneic HCT, of whom 17 (41%) were eligible for short-course EA therapy. Among eligible patients, the median age was 5.3 years, 47% had an underlying malignancy, and 88% received myeloablative conditioning. There were no differences in demographic or HCT characteristics between patients eligible for short-course EA during the intervention and preintervention period (n = 24). The short-course EA schedule was adhered to by 14 of the 17 eligible patients (82%). The duration of EA for first fever and total broad-spectrum antibiotic use was significantly decreased in the short-course EA-eligible patients compared to the preintervention cohort, from a median of 17 days to 8 days and from 20 days to 10 days, respectively (P < .01). Of the 14 patients adhering to short-course EA, 2 experienced a balancing measure of recurrent fever requiring resumption of EA, but no infection was identified. There were no BSIs, ICU admissions, or deaths during the hospitalization period in patients who received short-course EA. In this single-center QI project, short-course EA for initial fever was successfully applied to children undergoing allogeneic HCT using strict criteria and led to a significant decrease in broad-spectrum antibiotic use during hospitalization. These results should be validated in a prospective clinical trial to include the impact of short-course EA on antibiotic-resistant organisms, the intestinal microbiome, and HCT outcomes.
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Affiliation(s)
- Pratik A Patel
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia; Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia.
| | - Mehgan F Teherani
- Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yijin Xiang
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | | | - Shanmuganathan Chandrakasan
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kathryn P Goggin
- Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia
| | - Ann Haight
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Edwin Horwitz
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Wayne H Liang
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Suhag H Parikh
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Michelle L Schoettler
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | | | - Elizabeth Stenger
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Benjamin Watkins
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kirsten M Williams
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kathryn Leung
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Preeti Jaggi
- Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia
| | - Muna Qayed
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
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21
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Murillo-Maldonado MA, Galván PG, Ortega IP, Morales FG, Villegas LJ, Acosta ED. Long-term experience in treatment of acute promyelocytic leukemia in Mexican children in a tertiary care hospital. Front Oncol 2023; 13:1286106. [PMID: 38023223 PMCID: PMC10661391 DOI: 10.3389/fonc.2023.1286106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Acute promyelocytic leukemia (APL) is a rare myeloid leukemia subtype affecting adult and pediatric populations. APL constitutes 15-20% of all childhood AML in Latin America, compared to 7% in the non-Latino population. This leukemia has unique characteristics, such as its association with chromosomal translocations involving the retinoid acid receptor α (RARA) gene on chromosome 17. In addition, APL is also distinct from other AML subtypes due to its response to all-trans-retinoic acid (ATRA), which induces terminal granulocytic differentiation of blasts. Overall 5-year survival rates are generally reported to be greater than 80%. Materials and methods A study was conducted from January 2008 to December 2022 applying the IC-APL 2006 treatment protocol. This case series reports the clinical results of 22 children with APL. In all cases, the diagnosis was made by bone marrow aspiration and evaluation of the t(15:17) or t(11:17) transcripts. Results We identified 22 patients with APL, of whom 10 were female and 12 were male. Twelve patients debuted with coagulation abnormalities. The doses of anthracyclines varied according to the risk, with an average of 496.8 mgm2. The cardiological assessment was performed before and after chemotherapy, finding 2/22 patients with moderate sisto-diastolic dysfunction and one with mild pulmonary insufficiency at the end of treatment. There were 6/22 patients with complications related to ATRA treatment, the most frequent being pseudotumor cerebri. All complications were transitory and treated immediately without complications. In this series of cases, an overall survival of 90.6% and a relapse-free survival of 90.6% were recorded. The follow-up mean was 9.1 ± 3.8 years. Conclusion APL is a highly curable disease when combined with ATRA and anthracyclines. In this series of cases, good long-term results were observed with the IC-APL 2006 protocol. However, in Latin America, the availability of drugs such as arsenic trioxide as the first line of treatment is an unresolved challenge.
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Affiliation(s)
| | | | - Israel Parra Ortega
- Laboratory of Molecular Biology, Federico Gómez, Children’s Hospital of Mexico Federico Gómez, Mexico City, Mexico
| | - Félix Gaytán Morales
- Myeloid Leukemia Clinic, Federico Gómez, Children’s Hospital of Mexico, Mexico City, Mexico
- Hematopoietic Stem Cell Transplant Unit, Federico Gómez, Children’s Hospital of Mexico Federico Gómez, Mexico City, Mexico
| | - Luis Juárez Villegas
- Department of Hemato-Oncology, Federico Gómez, Children’s Hospital of Mexico Federico Gómez, Mexico City, Mexico
| | - Elisa Dorantes Acosta
- Myeloid Leukemia Clinic, Federico Gómez, Children’s Hospital of Mexico, Mexico City, Mexico
- Leukemia Cell Research Biobank, Federico, Gómez Children’s Hospital of Mexico, Mexico City, Mexico
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22
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Vargas C, Haeusler GM, Slavin MA, Babl FE, Mechinaud F, Phillips R, Thursky K, Lourenco RDA. An analysis of the resource use and costs of febrile neutropenia events in pediatric cancer patients in Australia. Pediatr Blood Cancer 2023; 70:e30633. [PMID: 37592047 DOI: 10.1002/pbc.30633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/31/2023] [Accepted: 08/05/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Febrile neutropenia (FN) in children with cancer generally requires in-hospital care, but low-risk patients may be successfully managed in an outpatient setting, potentially reducing the overall healthcare costs. Updated data on the costs of FN care are lacking. METHODS A bottom-up microcosting analysis was conducted from the healthcare system perspective using data collected alongside the Australian PICNICC (Predicting Infectious Complications of Neutropenic sepsis In Children with Cancer) study. Inpatient costs were accessed from hospital administrative records and outpatient costs from Medicare data. Costs were stratified by risk status (low/high risk) according to the PICNICC criteria. Estimated mean costs were obtained through bootstrapping and using a linear model to account for multiple events across individuals and other clinical factors that may impact costs. RESULTS The total costs of FN care were significantly higher for FN events classified as high-risk ($17,827, 95% confidence interval [CI]: $17,193-$18,461) compared to low-risk ($10,574, 95% CI: $9818-$11,330). In-hospital costs were significantly higher for high-risk compared to low-risk events, despite no differences in the cost structure, mean cost per day, and pattern of resource use. Hospital length of stay (LOS) was the only modifiable factor significantly associated with total costs of care. Excluding antineoplastics, antimicrobials are the most commonly used medications in the inpatient and outpatient setting for the overall period of analysis. CONCLUSION The FN costs are driven by in-hospital admission and LOS. This suggests that the outpatient management of low-risk patients is likely to reduce the in-hospital cost of treating an FN event. Further research will determine if shifting the cost to the outpatient setting remains cost-effective overall.
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Affiliation(s)
- Constanza Vargas
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Broadway, New South Wales, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- The Paediatric Integrated Cancer Service, Victoria State Government, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Francoise Mechinaud
- Unité d'hématologie Immunologie Pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, Paris, France
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, UK
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Broadway, New South Wales, Australia
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23
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De Pietri S, Weischendorff S, Rathe M, Frandsen TL, Hasle H, Nersting J, Nielsen CH, Moser C, Müller K. Gastrointestinal barrier integrity and mucosal inflammation as risk factors of blood stream infections in children treated for acute lymphoblastic leukaemia. Int J Cancer 2023; 153:1635-1642. [PMID: 37387257 DOI: 10.1002/ijc.34639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/08/2023] [Accepted: 06/14/2023] [Indexed: 07/01/2023]
Abstract
Chemotherapy-induced mucositis increases the risk of blood stream infections (BSI) due to translocation of bacteria across the intestinal epithelium. Our study investigated if quantitative measures of intestinal mucositis severity, including plasma citrulline (a marker of functional enterocytes) and CCL20 (an intestinal immune homeostatic chemokine), could identify patients at risk of BSI. A total of 106 children with ALL undergoing induction treatment (NOPHO ALL 2008) were included and information regarding BSI episodes was collected from the patients' medical records. Twenty-seven patients (25%) developed BSI during induction. Patients with BSI had a larger decrease in citrulline after chemotherapy than patients without BSI, and nearly all BSI episodes (25/27) occurred in the group of patients exhibiting a drop in citrulline (OR = 6.4 [95% CI: 1.4-29.3], P = .008). Patients who developed BSI had higher plasma CCL20 levels on days 8, 15 and 22 than patients without BSI (all P < .05), and elevated CCL20 levels on day 8 increased the risk of subsequent BSI (OR = 1.57 [1.11-2.22] per doubling of CCL20 level, P = .01) in a multivariable logistic regression analysis. These findings suggest that children with ALL who develop BSI during chemotherapy are characterised by more severe intestinal mucositis, as measured by plasma citrulline and CCL20. These markers may be useful in early risk stratification to guide treatment decisions.
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Affiliation(s)
- Silvia De Pietri
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sarah Weischendorff
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mathias Rathe
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Thomas Leth Frandsen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jacob Nersting
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Claus H Nielsen
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Klaus Müller
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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24
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Mendieta A, Rios Lopez L, Vargas Arteaga M, Maradiegue E, Delgadillo Arone W, Rueda Bazalar C, Holguin A, Santillan Salas C, Maza I, Homsi M, Farias Barrios F, Assayag C, Vásquez L, Pascual C, Caniza M. A multimodal strategy to improve health care for pediatric patients with cancer and fever in Peru. Rev Panam Salud Publica 2023; 47:e140. [PMID: 37799822 PMCID: PMC10548892 DOI: 10.26633/rpsp.2023.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/14/2023] [Indexed: 10/07/2023] Open
Abstract
Objective The DoTT (Decreasing Time to Therapy) project aimed to minimize the interval between fever onset and medical interventions for children with febrile neutropenia. The objective of this study was to determine the effect of implementing the DoTT project on the hospital time to antibiotic (TTA) and patient time to arrival (PTA) at the hospital in children with febrile neutropenia admitted to the emergency department. Methods The DoTT project was implemented at a Peruvian hospital and followed the World Health Organization (WHO) multimodal improvement strategy model. Components included creating a healthcare delivery bundle and antibiotic selection pathways, training users of the bundle and pathways, monitoring patient outcomes and obtaining user feedback, encouraging use of the new system, and promoting the integration of DoTT into the institutional culture. Emergency room providers were trained in the care delivery for children with cancer and fever and taught to use the bundle and pathways. DoTT was promoted via pamphlets and posters, with a view to institutionalizing the concept and disseminating it to other hospital services. Results Admission data for 129 eligible patients in our registry were analyzed. The TTA and PTA were compared before and after the DoTT intervention. The median TTA was 146 minutes (interquartile range [IQR] 97-265 minutes) before the intervention in 99 patients, and 69 minutes (IQR 50-120 minutes) afterwards in 30 patients (p < 0.01). The median PTA was reduced from 1 483 minutes at baseline to 660 minutes after the intervention (p < 0.01). Conclusions Applying the WHO multimodal improvement strategy model to the care of children with febrile neutropenia arriving at the hospital had a positive impact on the PTA and TTA, thus potentially increasing the survival of these patients.
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Affiliation(s)
- Ana Mendieta
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Ligia Rios Lopez
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Maria Vargas Arteaga
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Essy Maradiegue
- Instituto Nacional de Enfermedades NeoplásicasLimaPeruInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Walter Delgadillo Arone
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Carlos Rueda Bazalar
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Alexis Holguin
- Instituto Nacional de Enfermedades NeoplásicasLimaPeruInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | | | - Ivan Maza
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Maysam Homsi
- St. Jude Children’s Research HospitalMemphisUnited States of AmericaSt. Jude Children’s Research Hospital, Memphis, United States of America
| | | | - Claudia Assayag
- Hospital Nacional Edgardo Rebagliati MartinsLimaPeruHospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Liliana Vásquez
- Pan American Health OrganizationWashington, D.C.United States of AmericaPan American Health Organization, Washington, D.C., United States of America
| | - Claudia Pascual
- Pan American Health OrganizationLimaPeruPan American Health Organization, Lima, Peru
| | - Miguela Caniza
- St. Jude Children’s Research HospitalMemphisUnited States of AmericaSt. Jude Children’s Research Hospital, Memphis, United States of America
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Escobedo-Melendez G, Paniagua-Padilla J, Caniza MA. Outcomes of Care-bundle Implementation for Children With Cancer and Suspected Bloodstream Infection in a Pediatric Oncology Unit in a Resource-limited Setting. J Pediatr Hematol Oncol 2023; 45:e798-e809. [PMID: 37526415 PMCID: PMC10521769 DOI: 10.1097/mph.0000000000002719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 06/20/2023] [Indexed: 08/02/2023]
Abstract
Bloodstream infections (BSIs) are a major cause of mortality among pediatric oncology patients in resource-limited settings. Effective, innovative strategies are needed to improve care and survival. In a pediatric oncology unit in Mexico, we retrospectively analyzed the risk factors for mortality related to BSI and the results of using a care-bundle intervention. The care-bundle consisted of a swift clinical evaluation, initial fluid-resuscitation support, obtaining blood cultures, and administration of effective empirical antibiotic therapy for suspected BSI. The outcomes of patients who received the care-bundle during a 12-month period were compared with those of patients treated with standard care during the 12 months preceding its implementation. The primary outcomes were BSI diagnosis, choice of antibiotics, and mortality. Of the 261 suspected BSIs treated with standard care, 33 (12.6%) infections were confirmed, and of the 308 treated with the care-bundle, 67 (21.7%) BSIs were confirmed. Thus, after implementation of the care-bundle, significantly more BSIs were diagnosed ( P =0.004), and BSI-related mortality was significantly reduced by 22.2% ( P = 0.035). Surgical resection and mechanical ventilation support were independently associated with BSI-related mortality, and receiving effective initial empirical antibiotic therapy was protective against mortality (odds ratio, 0.013; 95% CI: 0.002-0.105; P =0.001), which comprising cefepime plus amikacin or meropenem in 44 (80.0%) of the cases alive. Consistent use of a care-bundle with initial fluid resuscitation, obtaining a blood culture, and administering effective antibiotics to children with cancer and suspected BSI can decrease mortality.
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Affiliation(s)
- Griselda Escobedo-Melendez
- Institute for Research in Childhood and Adolescence Cancer, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Jenny Paniagua-Padilla
- Institute for Research in Childhood and Adolescence Cancer, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Miguela A. Caniza
- Departments of Global Pediatric Medicine and Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN
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Yeoh DK, McMullan BJ, Clark JE, Slavin MA, Haeusler GM, Blyth CC. The Challenge of Diagnosing Invasive Pulmonary Aspergillosis in Children: A Review of Existing and Emerging Tools. Mycopathologia 2023; 188:731-743. [PMID: 37040020 PMCID: PMC10564821 DOI: 10.1007/s11046-023-00714-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/07/2023] [Indexed: 04/12/2023]
Abstract
Invasive pulmonary aspergillosis remains a major cause of morbidity and mortality for immunocompromised children, particularly for patients with acute leukaemia and those undergoing haematopoietic stem cell transplantation. Timely diagnosis, using a combination of computed tomography (CT) imaging and microbiological testing, is key to improve prognosis, yet there are inherent challenges in this process. For CT imaging, changes in children are generally less specific than those reported in adults and recent data are limited. Respiratory sampling by either bronchoalveolar lavage or lung biopsy is recommended but is not always feasible in children, and serum biomarkers, including galactomannan, have important limitations. In this review we summarise the current paediatric data on available diagnostic tests for IPA and highlight key emerging diagnostic modalities with potential for future use.
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Affiliation(s)
- Daniel K Yeoh
- Department of Infectious Diseases, Perth Children's Hospital, 15 Hospital Avenue, Perth, WA, 6009, Australia.
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia.
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Murdoch Children's Research Institute, Parkville, VIC, Australia.
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.
| | - Brendan J McMullan
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia
- School of Women's and Children's Health, UNSW, Sydney, NSW, Australia
| | - Julia E Clark
- Infection Management Service, Queensland Children's Hospital, Brisbane, QLD, Australia
- School of Clinical Medicine, Children's Health Queensland Clinical Unit, The University of Queensland, Brisbane, QLD, Australia
| | - Monica A Slavin
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Gabrielle M Haeusler
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Royal Children's Hospital, Parkville, VIC, Australia
- The Paediatric Integrated Cancer Service, Melbourne, VIC, Australia
| | - Christopher C Blyth
- Department of Infectious Diseases, Perth Children's Hospital, 15 Hospital Avenue, Perth, WA, 6009, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Department of Microbiology, PathWest Laboratory Medicine WA, Nedlands, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
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Prather CS, Wood JB, Mueller EL, Christenson JC, Alali M. The Yield, Safety, and Cost-effectiveness of Decreasing Repeat Blood Cultures Beyond 48 Hours in a Pediatric Hematology-Oncology Unit. J Pediatr Hematol Oncol 2023; 45:409-415. [PMID: 37526364 DOI: 10.1097/mph.0000000000002711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 06/13/2023] [Indexed: 08/02/2023]
Abstract
Clear recommendations are needed on when repeat blood cultures (BCxs) in hospitalized children with cancer should be obtained. We reviewed all BCx obtained on the Hematology-Oncology Unit at Riley Hospital for Children, regardless of reason for patient admission or neutropenia status, between January 2015 and February 2021. Patients with positive BCx within 48 hours of initial cultures, history of stem cell transplant, or admitted to the intensive care unit were excluded. Medical records of patients with new positive BCx drawn >48 hours after initial BCx were reviewed. Seven (1.2%) hospitalization episodes grew new pathogens, or commensals treated as pathogens, on cultures beyond 48 hours. All patients with new, true pathogens were hemodynamically unstable or had recurrent fever when the new positive BCx was obtained. Twenty-three (4.0%) hospitalization episodes had contaminant cultures beyond 48 hours, with 74 (5.4%) of 1362 BCx collected beyond 48 hours being contaminated, resulting in an additional cost of $210,519 from increased length of stay. In conclusion, repeat BCx beyond 48 hours in pediatric hematology-oncology patients with negative initial cultures are low yield and costly. Repeat BCx can be safely and cost-effectively ceased after 48 hours of negative cultures in hemodynamically and clinically stable patients.
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Affiliation(s)
| | - James B Wood
- Ryan White Center for Pediatric Infectious Diseases and Global Health
- Center for Pediatric and Adolescent Comparative Effectiveness Research
| | - Emily L Mueller
- Center for Pediatric and Adolescent Comparative Effectiveness Research
- Section of Pediatric Hematology-Oncology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | - Muayad Alali
- Ryan White Center for Pediatric Infectious Diseases and Global Health
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Rivetti S, Romano A, Mastrangelo S, Attinà G, Maurizi P, Ruggiero A. Aminoglycosides-Related Ototoxicity: Mechanisms, Risk Factors, and Prevention in Pediatric Patients. Pharmaceuticals (Basel) 2023; 16:1353. [PMID: 37895824 PMCID: PMC10610175 DOI: 10.3390/ph16101353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 09/17/2023] [Accepted: 09/21/2023] [Indexed: 10/29/2023] Open
Abstract
Aminoglycosides are broad-spectrum antibiotics largely used in children, but they have potential toxic side effects, including ototoxicity. Ototoxicity from aminoglycosides is permanent and is a consequence of its action on the inner ear cells via multiple mechanisms. Both uncontrollable risk factors and controllable risk factors are involved in the pathogenesis of aminoglycoside-related ototoxicity and, because of the irreversibility of ototoxicity, an important undertaking for preventing ototoxicity includes antibiotic stewardship to limit the use of aminoglycosides. Aminoglycosides are fundamental in the treatment of numerous infectious conditions at neonatal and pediatric age. In childhood, normal auditory function ensures adequate neurocognitive and social development. Hearing damage from aminoglycosides can therefore strongly affect the normal growth of the child. This review describes the molecular mechanisms of aminoglycoside-related ototoxicity and analyzes the risk factors and the potential otoprotective strategies in pediatric patients.
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Affiliation(s)
- Serena Rivetti
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.R.); (A.R.); (S.M.); (G.A.); (P.M.)
| | - Alberto Romano
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.R.); (A.R.); (S.M.); (G.A.); (P.M.)
| | - Stefano Mastrangelo
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.R.); (A.R.); (S.M.); (G.A.); (P.M.)
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giorgio Attinà
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.R.); (A.R.); (S.M.); (G.A.); (P.M.)
| | - Palma Maurizi
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.R.); (A.R.); (S.M.); (G.A.); (P.M.)
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.R.); (A.R.); (S.M.); (G.A.); (P.M.)
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Safari LC, Mloka D, Minzi O, Dharsee NJ, Reuben R. Prevalence of blood stream infections and associated factors among febrile neutropenic cancer patients on chemotherapy at Ocean Road Cancer Institute, Tanzania. Infect Agent Cancer 2023; 18:52. [PMID: 37730617 PMCID: PMC10510178 DOI: 10.1186/s13027-023-00533-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/12/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Febrile Neutropenia (FN) caused by bacteria in cancer patients is associated with poor prognosis. The aim of this study was to determine the prevalence of FN and associated factors among cancer patients on chemotherapy at Ocean Road Cancer Institute (ORCI), Tanzania. METHODS A cross-sectional study was conducted from June to September 2019. Study participants were conveniently recruited. A desk review of participants medical records was performed. Standard microbiological procedures used to culture and identify the bacterial isolates from the positive blood cultures of participants that presented with FN. Kirby-Bauer disc diffusion was used to perform the antibiotics susceptibility testing. SPSS version 20.0 and MS Excel were used in data entry and analysis. Chi-Square was used as a measure of association between various factors and neutropenia. P-value less than 0.05 was considered statistically significant. RESULTS A total 213 participants were enrolled. Of these 76.1% were female. Most of the participants came from the Coast region. Majority of participants presented with breast Cancer (36.2%) and GIT (20.2%). The prevalence of FN and bacteremia was 5.6% and 35.3% respectively. Staphylococcus Aureus (60%) and Coagulase-Negative Staphylococci (40%) were the main isolates. Of the 6 isolates tested most were resistant to Co-Trimoxazole 4/6 (66.7%) and Doxycycline 3/6 (50%). FN was positively associated with chemotherapy regimen (P = 0.0001), platelets count (P = 0.0001) and use of G-CSF (P = 0.0001). CONCLUSION The prevalence of FN among the cancer patients on chemotherapy in Tanzania is low but associated with drug-resistant bacteria.
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Affiliation(s)
- Lambert C Safari
- Department of Clinical Pharmacy and Pharmacy Practice, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Huye, Rwanda.
- University Teaching Hospital of Butare (CHUB), Huye, Rwanda.
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Doreen Mloka
- Pharmaceutical Microbiology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Omary Minzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nazima J Dharsee
- Department of Clinical Oncology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Rabson Reuben
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
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Srinivasan P, Meena JP, Gupta AK, Halder A, Kapil A, Pandey RM, Seth R. Safety of Procalcitonin Guided Early Discontinuation of Antibiotic Therapy among Children Receiving Cancer Chemotherapy and Having Low-Risk Febrile Neutropenia: A Randomized Feasibility Trial (ProFenC Study). Pediatr Hematol Oncol 2023; 41:89-102. [PMID: 37655541 DOI: 10.1080/08880018.2023.2249940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/02/2023]
Abstract
In low-risk febrile neutropenia (LR-FN), the safety of early discontinuation of empiric antibiotics without marrow recovery is not well established. This study aimed to evaluate the safety of procalcitonin (PCT) guided early discontinuation of antibiotics in LR-FN. In this trial, children with LR-FN with an afebrile period of at least 24 h, sterile blood culture, and negative/normalized PCT were randomized at 72 h of starting antibiotics into two groups: intervention arm and standard arm. The antibiotics were stopped in the intervention arm regardless of absolute neutrophil count (ANC), while in the standard arm, antibiotics were continued for at least 7 days or until recovery of ANC (>500/mm3). The primary objective was to determine the treatment failure rates, and the secondary objective was to compare the duration of antibiotics and all-cause mortality between the two arms. A total of 46 children with LR-FN were randomized to either the intervention arm (n = 23) or the standard arm (n = 23). Treatment failure was observed in 2/23 (8.7%) of patients in the intervention arm compared to 1/23 (4.3%) in the standard arm [RR: 2 (95% CI: 0.19-20.6); p = 0.55]. The median duration of antibiotics in the intervention arm and standard arm were 3 days vs 7 days (P= <0.001). There was no mortality in this study. PCT-guided early discontinuation of empirical antibiotics in LR-FN is feasible. There was no significant difference observed in treatment failure between the early discontinuation of antibiotics vs standard therapy. The total duration of antibiotic exposure was significantly lesser in the discontinuation arm. Further, larger multicenter studies are needed to confirm the finding of this study.
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Affiliation(s)
- Prasanth Srinivasan
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jagdish Prasad Meena
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Kumar Gupta
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Ashutosh Halder
- Department of Reproductive Biology, All India Institute of Medical Sciences, New Delhi, India
| | - Arti Kapil
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra Mohan Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Rachna Seth
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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de la Maza V, Fuentes V, Cabrolier E, Fernández MS, Saéz S, Concha C, Nicklas C, Castro M, Torres JP. Efficacy, Safety, and Pain Level of Subcutaneous Catheter Use for Administration of Granulocyte Colony-Stimulating Factor (G-CSF) in Children With Cancer: A Randomized Pilot Study. JOURNAL OF PEDIATRIC HEMATOLOGY/ONCOLOGY NURSING 2023; 40:305-312. [PMID: 37920922 DOI: 10.1177/27527530231190373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Background: The aim of this study was to explore the efficacy, safety, and pain level of granulocyte colony-stimulating factor (G-CSF) administration via a subcutaneous catheter compared with direct injection in children with cancer. Method: This was a pilot randomized controlled trial of standard G-CSF administration versus subcutaneous catheter administration. Children 2-15 years of age who were beginning G-CSF after their first chemotherapy cycle and anticipated to receive G-CSF following the next three cycles of chemotherapy were eligible. Efficacy, safety, and pain were as outcomes of the study. Results: Twenty-nine children with cancer (median age 12 years) were enrolled in the study (16 children in the subcutaneous catheter group and 13 children in the direct injection group). During Cycle 2, the median number of days to reach absolute neutrophil count (ANC) ≥ 500/mm3 was greater among those in the subcutaneous catheter group (12 vs. 10; p = .02). In Cycle 3, however, the subcutaneous catheter group received fewer doses of G-CSF (8 vs. 12; p = .004). No complications related to subcutaneous catheter use were observed. No differences in the visual analog scale pain score were observed between groups in Cycles 1 to 3; however, in Cycle 4, children in the subcutaneous catheter group had lower median pain scores than those in the direct subcutaneous injection group (Mdn = 0, [IQR] = 0-2 vs. Mdn = 1, IQR = 0-6; p < 0.01). Conclusion: Results demonstrated administering G-CSF via a subcutaneous catheter enables ANC to recover with no pain or complications associated with its use. Thus, oncology teams may consider this administration method to be used in children with cancer.
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Affiliation(s)
- Verónica de la Maza
- Pediatrics and Pediatric Surgery Department, Dr. Luis Calvo Mackenna Hospital, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Valeska Fuentes
- Oncology Unit, Dr. Luis Calvo Mackenna Hospital, Santiago, Chile
| | - Elisa Cabrolier
- Hematopoietic Transplant Unit, Dr. Luis Calvo Mackenna Hospital, Santiago, Chile
| | | | - Sara Saéz
- Hematopoietic Transplant Unit, Dr. Luis Calvo Mackenna Hospital, Santiago, Chile
| | - Claudia Concha
- Oncology Unit, Dr. Luis Calvo Mackenna Hospital, Santiago, Chile
| | - Carolina Nicklas
- Oncology Unit, Dr. Luis Calvo Mackenna Hospital, Santiago, Chile
| | - Magdalena Castro
- Research and Epidemiology Unit, Medical School, Universidad Finis Terrae, Santiago, Chile
| | - Juan Pablo Torres
- Pediatrics and Pediatric Surgery Department, Dr. Luis Calvo Mackenna Hospital, Faculty of Medicine, Universidad de Chile, Santiago, Chile
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Vieira Filho JF, Ribeiro VN, do Nascimento ÁMA, Maria Alves de Melo M. Infections in Children with Cancer Admitted in an Oncology Reference Hospital: A Cross-sectional Study. Curr Microbiol 2023; 80:315. [PMID: 37544971 DOI: 10.1007/s00284-023-03420-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 07/17/2023] [Indexed: 08/08/2023]
Abstract
Pediatric oncology patients are usually immunosuppressed due to factors such as the neoplasm and its treatment, making them more susceptible to infections. This article aims to determine the infection profile of pediatric oncology patients admitted to an oncology reference hospital in Natal, Rio Grande do Norte, Brazil. A retrospective and cross-sectional study was conducted, collecting data from patients hospitalized due to infection in a pediatric oncology unit exclusively for the Brazilian public health system, spanning from 2018 to 2021. A total of 168 episodes of infections were identified in 96 patients, resulting in 157 hospitalizations. Among the patients with infections, 62.4% had hematological malignancies, and out of these cases, 74.6% specifically had Acute Lymphoid Leukemia. The Escherichia coli (31.9%) was the most prevalent microorganism isolated from the samples. Multidrug-resistant microorganisms accounted for 52% of all identified microorganisms. Fluoroquinolones and beta-lactam were the most prevalent antibiotic classes in the analyzed antibiograms. Factors such as Sex, type of cancer, chemotherapy in the last 30 days, were found to be associated with the occurrence of infection (p < 0.05). Conducting epidemiological studies regarding infections in pediatric oncology is crucial to development of empirical protocols, and the implementation of strategies to better control future infections.
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Affiliation(s)
- Jonas Fernandes Vieira Filho
- Instituto de Ensino, Pesquisa e Inovação, Liga Norte Riograndense Contra o Câncer Hospital, Natal, Rio Grande do Norte, Brazil
| | - Viviane Nunes Ribeiro
- Instituto de Ensino, Pesquisa e Inovação, Liga Norte Riograndense Contra o Câncer Hospital, Natal, Rio Grande do Norte, Brazil
| | | | - Menilla Maria Alves de Melo
- Instituto de Ensino, Pesquisa e Inovação, Liga Norte Riograndense Contra o Câncer Hospital, Natal, Rio Grande do Norte, Brazil.
- Department of Pharmacy, Pesquisa e Inovação, Instituto de Ensino, Liga Norte Riograndense Contra o Câncer Hospital, Av. Miguel Castro, Nossa Senhora de Nazaré, Natal, 1355, CEP 59062-000, Rio Grande do Norte, Brazil.
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Lemiech-Mirowska E, Gaszyńska E, Sierocka A, Kiersnowska Z, Marczak M. Clostridioides difficile Infections among Pediatric Patients Hospitalized at an Oncology Department of a Tertiary Hospital in Poland. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1363. [PMID: 37629653 PMCID: PMC10456884 DOI: 10.3390/medicina59081363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/16/2023] [Accepted: 07/20/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Gastrointestinal tract infections caused by Clostridioides difficile bacteria are diagnosed in pediatric patients with increasing frequency. Children treated at pediatric units are a group of patients at high risk of this infection; therefore, appropriate differential diagnostics and an individual approach to every case are of particular importance. The goal of the study was to assess the clinical parameters of patients with a confirmed CD infection and colonization. Materials and Methods: Every positive case was subjected to a retrospective analysis based on medical history and an infection notification note. Results: Positive results were obtained for 30 patients, among whom the results of 18 patients were considered to justify the diagnosis of an infection. In the remaining patients, treatment was not initiated in only three cases. Cases were detected where treatment was initiated despite the lack of sufficient clinical evidence. Conclusions: This study demonstrates that there are many factors that result in a high risk of the occurrence of CDI in oncology patients, such as antibiotic therapy, multiple hospitalizations, and myelosuppression.
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Affiliation(s)
- Ewelina Lemiech-Mirowska
- Department of Management and Logistics in Healthcare, Medical University of Lodz, 90-419 Lodz, Poland; (A.S.); (Z.K.); (M.M.)
| | - Ewelina Gaszyńska
- Department of Nutrition and Epidemiology, Medical University of Lodz, 90-419 Lodz, Poland;
| | - Aleksandra Sierocka
- Department of Management and Logistics in Healthcare, Medical University of Lodz, 90-419 Lodz, Poland; (A.S.); (Z.K.); (M.M.)
| | - Zofia Kiersnowska
- Department of Management and Logistics in Healthcare, Medical University of Lodz, 90-419 Lodz, Poland; (A.S.); (Z.K.); (M.M.)
| | - Michał Marczak
- Department of Management and Logistics in Healthcare, Medical University of Lodz, 90-419 Lodz, Poland; (A.S.); (Z.K.); (M.M.)
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Asleh M, Khalaila A, Yousef R, Leibovitz E, Danino D. Comparison Between Peripheral and Central Blood Cultures in Pediatric Oncology Patients With Blood Stream Infections. J Pediatr Hematol Oncol 2023; 45:e590-e596. [PMID: 37027244 DOI: 10.1097/mph.0000000000002666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 02/20/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Current guidelines for fever in children with cancer recommend obtaining blood cultures from all lumens of the central venous catheter (CVC) and to consider a concurrent peripheral blood culture. We assessed the characteristics of blood stream infections (BSI) in oncology children and compared central and peripheral pathogen growth. METHODS A prospective, computerized surveillance of BSI in children treated at the oncology unit between May 2014 and July 2020. The growth of the same organism within a month was considered a single episode, ≥2 organisms in the same culture were defined as different episodes. Only children with concomitant cultures, drawn at presentation before initiation of antibiotics were included in the comparison between CVC and peripheral cultures. RESULTS A total of 139 episodes in 81 children (with implanted Port-A-catheters) were considered true BSI. Of the 94/139 (67.6%) cases where a central and peripheral culture were concomitantly obtained, 52/94 (55.3%) had positive central/peripheral cultures that grew the same organism, 31/94 (33.0%) had positive central cultures only, and 11/94 (11.7%) had positive peripheral cultures only. In 3/94 cases, the organisms that grew from the CVC were not identical to those from the peripheral site. Four of 52 (7.7%) of the same positive central/peripheral pathogens had different susceptibility testing results. Higher CVC removal rates were observed when both peripheral and CVC cultures were positive ( P =0.044). CONCLUSIONS Overall, 11.7% of BSI episodes were identified only by peripheral culture and 7.7% of paired organisms did not share the same susceptibility test results which emphasizes the importance of a peripheral culture in managing fever in oncology children.
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Affiliation(s)
- Mahdi Asleh
- Faculty of Health Sciences, Ben-Gurion University of the Negev
- Hemato-Oncology Department, Soroka University Medical Center
| | - Aya Khalaila
- Faculty of Health Sciences, Ben-Gurion University of the Negev
- Hemato-Oncology Department, Soroka University Medical Center
| | - Remah Yousef
- Faculty of Health Sciences, Ben-Gurion University of the Negev
- Pediatric Department
| | - Eugene Leibovitz
- Faculty of Health Sciences, Ben-Gurion University of the Negev
- The Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel
| | - Dana Danino
- Faculty of Health Sciences, Ben-Gurion University of the Negev
- The Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel
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Carolan PL, Lammers SM, Anderson CM, Messinger YH. Effect of Prearrival Orders on Time to Antibiotics for Immunocompromised Oncology Patients Presenting to the Emergency Department With Fever. Pediatr Emerg Care 2023; 39:470-475. [PMID: 36066576 DOI: 10.1097/pec.0000000000002822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Pediatric cancer patients with fever are at risk for invasive bacterial infection. The administration of antibiotics to these patients within the first hour of evaluation is viewed as a quality of care metric with potential to improve outcome. We sought to evaluate the impact of prearrival patient orders on the timeliness of antibiotic administration for this patient population presenting to the emergency department (ED) because of fever. METHODS A single-site pediatric ED intervention study was performed. Four hundred thirty-nine consecutively referred febrile immunocompromised pediatric oncology patients were included in the study. The intervention used structured monthly messages sent to oncology and emergency medicine providers highlighting specific roles in prehospital communication and in ED-based care emphasizing the use of standardized, prearrival order (PAO) sets. Primary outcome measures were time to antibiotic administration (TTA) and the proportions of patients receiving PAO placement and antibiotics within 60 minutes of ED arrival. Results were analyzed for the preintervention (September 2016-July 2017), intervention (August 2017-February 2018), and postintervention (March-December 2018) periods. RESULTS Improvements occurred across the study periods in the proportion of patients with PAO placement (preintervention, 68%; intervention, 82%; postintervention, 87%; P = 0.001) as well as in the percentages of patients receiving antibiotics in less than 60 minutes (preintervention, 73%; intervention, 84%; postintervention, 85%; P = 0.02). Median TTA decreased from 48 to 40 minutes ( P = 0.018). Linear regression with TTA as a dependent variable revealed that PAO placement predicted a shorter TTA, decreasing by more than 15 minutes ( B = -15.90; [95% confidence interval, -20.03--11.78]; P < 0.001). CONCLUSIONS Standardizing elements of prehospital communication and ED-based care using PAO sets resulted in significant improvements in time to antibiotics and in the proportion of febrile immunocompromised oncology patients receiving antibiotics within 60 minutes of ED arrival.
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Affiliation(s)
| | | | - Cynthia M Anderson
- Department of Hematology Oncology, Children's Minnesota, Minneapolis, MN
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Givone A, Duval-Destin J, Delebarre M, Abou-Chahla W, Lervat C, Dubos F. Consensus survey on the management of children with chemotherapy-induced febrile neutropenia and at low risk of severe infection. Pediatr Hematol Oncol 2023; 41:172-178. [PMID: 37293777 DOI: 10.1080/08880018.2023.2218406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/21/2023] [Indexed: 06/10/2023]
Abstract
Our aim was to identify national consensus criteria for the management of children with chemotherapy-induced febrile neutropenia (FN), for evidence-based step-down treatment approaches for patients classified at low risk of severe infection. In 2018, a five-section, 38-item survey was e-mailed to all pediatric hematology and oncology units in France (n = 30). The five sections contained statements on possible consensus criteria for the (i) definition of FN, (ii) initial management of children with FN, (iii) conditions required for initiating step-down therapy in low-risk patients, (iv) management strategy for low-risk patients, and (v) antibiotic treatment on discharge. Consensus was defined by respondents' combined answers (somewhat agree and strongly agree) at 75% or more. Sixty-five physicians (participation rate: 58%), all specialists in pediatric onco-hematology, from 18 centers completed the questionnaire. A consensus was reached on 22 of the 38 statements, including the definition of FN, the criteria for step-down therapy in low-risk children, and the initial care of these patients. There was no consensus on the type and duration of antibiotic therapy on discharge. In conclusion, a consensus has been reached on the criteria for initiating evidence-based step-down treatment of children with FN and a low risk of severe infection but not for the step-down antimicrobial regimen.
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Affiliation(s)
- Aude Givone
- Pediatric Emergency Unit & Infectious Diseases, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jean Duval-Destin
- Pediatric Emergency Unit & Infectious Diseases, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Mathilde Delebarre
- Pediatric Emergency Unit & Infectious Diseases, Centre Hospitalier Universitaire de Lille, Lille, France
- Pediatric Emergency Unit, Saint-Vincent-de-Paul Hospital, GHICL, Lille, France
| | - Wadih Abou-Chahla
- Pediatric Hematology Unit, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Cyril Lervat
- Pediatric Oncology Unit, Oscar Lambret Cancer Center, Lille, France
| | - François Dubos
- Pediatric Emergency Unit & Infectious Diseases, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Université de Lille, Lille, France
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Cebron C, Smiljkovic M, Percheron L, Caspar Y, Arata-Bardet J, Mortamet G, Martinod M. Carbapenem prescriptions: Compliance with guidelines in a pediatric hospital. Arch Pediatr 2023:S0929-693X(23)00078-7. [PMID: 37286425 DOI: 10.1016/j.arcped.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 05/02/2023] [Accepted: 05/07/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND This study aimed to describe the use of carbapenems in a pediatric tertiary center and to assess its compliance with national and local guidelines. METHODS This retrospective study focused on children who received at least one dose of carbapenems in a tertiary university hospital over a 1-year period (2019). The appropriateness of each prescription was assessed. RESULTS In total, 96 prescriptions were collected for 75 patients (median age 3 years [interquartile range, IQR: 0-9]). Most prescriptions were empirical (n = 77, 80%) and mainly concerned nosocomial infections (n = 69, 72%). At least one risk factor for extended-spectrum beta-lactamases was found in 48% (n = 46) of cases. The median duration of treatment with carbapenems was 5 days and it was over 7 days in 38% (n = 36) of cases. The use of carbapenems was considered appropriate in 95% (18/19) and 70% (54/77) of cases when therapy was guided by culture results or was empirical, respectively. De-escalation of carbapenem treatment within 72 h occurred in 31% (n = 30) of cases. CONCLUSION The use of carbapenems can be optimized in the pediatric population, even when the initial prescription for a carbapenem is considered appropriate.
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Affiliation(s)
- Clara Cebron
- Pediatric Department, Grenoble-Alpes University Hospital, La Tronche, France
| | - Mina Smiljkovic
- Pediatric Department, Grenoble-Alpes University Hospital, La Tronche, France
| | - Lucas Percheron
- Pediatric Department, Toulouse University Hospital, Toulouse, France
| | - Yvan Caspar
- Microbiology, Grenoble-Alpes University Hospital, La Tronche, France
| | - Julie Arata-Bardet
- Pediatric Department, Grenoble-Alpes University Hospital, La Tronche, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, La Tronche, France.
| | - Marie Martinod
- Pediatric Department, Grenoble-Alpes University Hospital, La Tronche, France
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Khairullah A, Garner LM, DeMarco M, Wilson WS. Characterization of Febrile Neutropenia Management in Children With Malignancies: A Single-Center Evaluation. J Pediatr Pharmacol Ther 2023; 28:235-240. [PMID: 37303769 PMCID: PMC10249966 DOI: 10.5863/1551-6776-28.3.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/13/2022] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Current recommendations for febrile neutropenia (FN) include initiation of broad-spectrum antibiotics without clear indications of when or how to de-escalate or target therapy, especially in those without microbiologically defined bloodstream infections (MD-BSIs). The purpose of this study is to characterize a pediatric FN population, FN management, and identify the proportion of patients with MD-BSI. METHODS This study was a single-center, retrospective chart review of patients admitted to the University of North Carolina Children's Hospital between January 1, 2016, and December 31, 2019, with a diagnosis of FN. RESULTS There were 81 unique encounters included in this study. MD-BSI was the etiology of fever in 8 FN episodes (9.9%). The most common empiric antibiotic regimen was cefepime (62%) followed by cefepime and vancomycin (25%). The most common de-escalation type was the discontinuation of vancomycin (83.3%), and the most common type of escalation was the addition of vancomycin (50%). The median antibiotic total duration in patients without MDI-BSI was 3 days (IQR, 5-9). CONCLUSIONS In this single-center, retrospective review, most FN episodes were not due to an MD-BSI. There were inconsistencies in practice of when discontinuation of antibiotic therapy occurred in patients without MD-BSI. De-escalation or cessation of antibiotic therapy before neutropenia resolution did not result in any documented complication. These data suggest a role for implementing an institutional guideline to improve consistency in antimicrobial use in pediatric patients with febrile neutropenia.
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Affiliation(s)
- Amanie Khairullah
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
| | - Lauren M. Garner
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
| | - Mia DeMarco
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
| | - William S. Wilson
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
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Yang M, Lu X, Xin L, Luo J, Diao S, Jia Z, Cheng G, Zeng L, Zhang L. Comparative effectiveness and safety of antibiotic prophylaxis during induction chemotherapy in children with acute leukaemia: a systematic review and meta-analysis. J Hosp Infect 2023; 136:20-29. [PMID: 36921630 DOI: 10.1016/j.jhin.2023.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/20/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Bacterial infections are common during induction therapy in children and adolescents with acute leukaemia and may cause infection-related mortality. AIM To determine the efficacy and safety of prophylactic antibiotics in paediatric patients with acute leukaemia receiving induction chemotherapy. METHODS From three English databases and four Chinese databases, we searched for randomized controlled trials (RCTs) and cohort studies that compared prophylactic antibiotics to placebo, no prophylaxis, or that compared one antibiotic versus another in paediatric patients with acute leukaemia undergoing induction chemotherapy. Two reviewers independently screened the studies, extracted data, and assessed the risk of bias using Cochrane Risk of Bias 2 tool and Newcastle-Ottawa Scale, and the certainty of evidence using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). FINDINGS Two RCTs and ten cohort studies were finally included. For children with acute lymphoblastic leukaemia, antibiotic prophylaxis, including levofloxacin, sulfamethoxazole-trimethoprim, or other antibiotics, probably reduced bacteraemia (risk ratio (RR): 0.44; 95% confidence interval (CI): 0.33-0.60; moderate certainty) without significantly increasing Clostridioides difficile infection (CDI) or invasive fungal infection. Levofloxacin reduced the CDI rate (RR: 0.08; 95% CI: 0.01-0.62; high certainty). Ciprofloxacin prophylaxis probably reduced infection-related mortality (RR: 0.12; 95% CI: 0.01-0.97; moderate certainty). In children with acute myeloid leukaemia, ciprofloxacin plus vancomycin may reduce febrile neutropenia (RR: 0.79; 95% CI: 0.66-0.94; low certainty). Individual studies indicated that prophylaxis increased antibiotic exposure but reduced non-preventive antibiotic exposure. CONCLUSION In children with acute leukaemia undergoing induction therapy, antibiotic prophylaxis may improve the bacterial infection and mortality.
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Affiliation(s)
- M Yang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China; Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China; NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; West China School of Medicine, Sichuan University, Chengdu, China
| | - X Lu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; Department of Paediatric Haematology and Oncology, West China Second Hospital, Sichuan University, Chengdu, China
| | - L Xin
- Department of Clinical Pharmacy, The Affiliated Hospital of Yunnan University, Kunming, China
| | - J Luo
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China; Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China; NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; West China School of Pharmacy, Sichuan University, Chengdu, China
| | - S Diao
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China; Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China; NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Z Jia
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China; Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China; NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; West China School of Pharmacy, Sichuan University, Chengdu, China
| | - G Cheng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China; Laboratory of Molecular Translational Medicine, Center for Translational Medicine, Sichuan University, Chengdu, China
| | - L Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China; Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China; NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China.
| | - L Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China; Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China; NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China.
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Novrianda D, Herini ES, Haryanti F, Supriyadi E, Lazuardi L. Chemo assist for children mobile health application to manage chemotherapy-related symptoms in acute leukemia in Indonesia: a user-centered design approach. BMC Pediatr 2023; 23:274. [PMID: 37254039 DOI: 10.1186/s12887-023-04076-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 05/16/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND A mobile health (mHealth) application can encourage parents and pediatric patients to be involved in caring for their child's health condition by providing the ability to identify and actively manage chemotherapy-related symptoms in their child. Several monitoring systems available today are diverse in features and system basis. This study aimed to develop and trial the Chemo Assist for Children (CAC) mHealth application for symptom management in children with acute lymphoblastic leukemia (ALL). METHODS In this study, the development of the CAC application went through multiple phases and methods. Study phases included: (1) development of the application's feature based on the need assessment, (2) creation of content of application based on literature review, (3) develop prototyping of CAC, (4) expert review and feedback on the application content, (5) usability testing by targeted end-user. RESULTS Based on need assessment, it was determined that parents with leukemia children were interested in symptom management of chemotherapy and preferred mobile applications. Therefore, a mHealth application was designed to include features to identify symptoms and provide recommendation strategies to manage the symptom. Usability evaluation by end-user revealed that mHealth is a valid, accessible, and appropriate application for users. CONCLUSIONS The CAC mHealth application developed can meet the needs of technology users to identify symptoms and manage chemotherapy-related symptoms in children with ALL. The CAC mHealth application can accommodate data not recorded at out-of-hospital care, increase the independence of symptom management, and improve communication between parents of children with ALL and health workers.
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Affiliation(s)
- Dwi Novrianda
- Department of Pediatrics and Maternity Nursing, Faculty of Nursing, Universitas Andalas, Padang, Indonesia
| | - Elisabeth Siti Herini
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia.
| | - Fitri Haryanti
- Department of Pediatric-Maternity Nursing, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Eddy Supriyadi
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Lutfan Lazuardi
- Department of Health Policy and Management, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
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Kourti M, Chorafa E, Roilides E, Iosifidis E. Antifungal Stewardship Programs in Children: Challenges and Opportunities. Pediatr Infect Dis J 2023; Publish Ahead of Print:00006454-990000000-00467. [PMID: 37257114 DOI: 10.1097/inf.0000000000003967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Maria Kourti
- From the 3rd Department Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Hippokration General Hospital, Thessaloniki, Greece
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Sara C, Davide L, Nunzia L, Tamara B, Luca P, Daniele Z, Marcello L, Arcangelo P, Riccardo M. The role of presepsin in pediatric patients with oncological and hematological diseases experiencing febrile neutropenia. Sci Rep 2023; 13:6464. [PMID: 37081067 PMCID: PMC10119114 DOI: 10.1038/s41598-023-33094-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/06/2023] [Indexed: 04/22/2023] Open
Abstract
Febrile neutropenia (FN) represents one of the main complications of pediatric patients with oncological and hematological diseases. In these patients, it is crucial to identify bacterial infections. The aim of this study is to evaluate presepsin as an early biomarker of bacterial infections during FN. We compared patients with oncological and hematological diseases and a 2:1 age-matched healthy control group. In the FN group, we evaluated 4 biomarkers, namely, C reactive protein (CRP), procalcitonin (PCT), interleukin 6 (IL6) and presepsin at the onset of fever (T0) and 48 h after T0 (T1). In the control group, we only evaluated presepsin. We enrolled a total of 41 children with oncological and hematological diseases disease experiencing 50 FN episodes and 100 healthy patients in the control group. In patients with FN, we found that presepsin was significantly higher than in the control group (p < 0.001). However, in the FN group, we did not find a statistically significant difference between patients with and without bacteremia (p = 0.989 at T0, p = 0.619 at T1). Presepsin values at T1 were higher in patients experiencing an unfavorable outcome (p = 0.025). This study shows that presepsin increases in neutropenic patients, but it only revealed useful in predicting an unfavorable outcome 48 h from the onset of fever.
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Affiliation(s)
- Cerasi Sara
- Pediatric Oncology and Hematology "Lalla Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Giuseppe Massarenti 11, 40138, Bologna, Italy
| | - Leardini Davide
- Pediatric Oncology and Hematology "Lalla Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Giuseppe Massarenti 11, 40138, Bologna, Italy.
| | - Lisanti Nunzia
- Pediatric Oncology and Hematology "Lalla Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Giuseppe Massarenti 11, 40138, Bologna, Italy
| | - Belotti Tamara
- Pediatric Oncology and Hematology "Lalla Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Giuseppe Massarenti 11, 40138, Bologna, Italy
| | - Pierantoni Luca
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138, Bologna, Italy
| | - Zama Daniele
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138, Bologna, Italy
| | - Lanari Marcello
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138, Bologna, Italy
| | - Prete Arcangelo
- Pediatric Oncology and Hematology "Lalla Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Giuseppe Massarenti 11, 40138, Bologna, Italy
| | - Masetti Riccardo
- Pediatric Oncology and Hematology "Lalla Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Giuseppe Massarenti 11, 40138, Bologna, Italy
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Mackie DB, Kuo D, Paul M, Elster J. Does Fever Response to Acetaminophen Predict Bloodstream Infections in Febrile Neutropenia? Cureus 2023; 15:e36712. [PMID: 37113346 PMCID: PMC10129031 DOI: 10.7759/cureus.36712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 03/28/2023] Open
Abstract
BACKGROUND There is a need to identify clinical parameters for early and effective risk stratification and prediction of bacterial bloodstream infections (BSIs) in patients with febrile neutropenia (FN). Acetaminophen is used widely to treat fever in FN; however, little research exists on whether fever response to acetaminophen can be used as a predictor of BSIs. OBJECTIVES Investigate the relationship between fever response to acetaminophen and bacteremia in FN. DESIGN/METHOD A retrospective review of patients (1-21 years old) presenting with FN and bacteremia at Rady Children's Hospital (2012-2018) was performed. Demographic information, presenting signs/symptoms, degree of neutropenia (absolute neutrophil count (ANC) > 500 or < 500 cells/µL), absolute monocyte count, blood culture results, temperatures one, two, and six hours after acetaminophen, and timing of antibiotic administration were examined. Patients were stratified into three malignancy categories: leukemia/lymphoma, solid tumor, and hematopoietic stem cell transplant. Patients were matched with culture-negative controls based on sex, age, malignancy category, and degree of neutropenia. RESULTS Thirty-five case-control pairs met inclusion criteria (70 presentations of FN). The mean age of the cases was 10.7 years (± 6.3) vs. 10.0 years (± 5.9) for the controls. Twenty were female (57%). Twenty-three pairs were categorized as leukemia/lymphoma (66%), eight as solid tumors (23%), and four as HSCT (11%). Thirty-four pairs (97%) had a presenting ANC < 500 cells/µL. Higher temperature one-hour post-acetaminophen was associated with bacteremia (p = 0.04). Logistic regression demonstrated that temperature one-hour post-acetaminophen had a significant predictive value for bacteremia (p = 0.011). The area under the receiver operating characteristic curves for logistic regression and classification and regression tree analysis were 0.70 and 0.71, respectively. CONCLUSION While temperature one-hour post-acetaminophen was higher among patients with bacteremia and was a significant predictor of bacteremia, fever response in isolation lacks sufficient predictive value to impact clinical decision-making. Future studies are needed to assess fever responsiveness as an adjunct to existing modalities of FN risk stratification.
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Lehrnbecher T, Robinson PD, Ammann RA, Fisher B, Patel P, Phillips R, Beauchemin MP, Carlesse F, Castagnola E, Davis BL, Elgarten CW, Groll AH, Haeusler GM, Koenig C, Santolaya ME, Tissing WJ, Wolf J, Alexander S, Hu H, Dupuis LL, Sung L. Guideline for the Management of Fever and Neutropenia in Pediatric Patients With Cancer and Hematopoietic Cell Transplantation Recipients: 2023 Update. J Clin Oncol 2023; 41:1774-1785. [PMID: 36689694 PMCID: PMC10022858 DOI: 10.1200/jco.22.02224] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/09/2022] [Accepted: 12/13/2022] [Indexed: 01/24/2023] Open
Abstract
PURPOSE To update a clinical practice guideline (CPG) for the empiric management of fever and neutropenia (FN) in pediatric patients with cancer and hematopoietic cell transplantation recipients. METHODS The International Pediatric Fever and Neutropenia Guideline Panel reconvened to conduct the second update of this CPG. We updated the previous systematic review to identify new randomized controlled trials (RCTs) evaluating any strategy for the management of FN in pediatric patients. Using the Grading of Recommendations Assessment, Development and Evaluation framework, evidence quality was classified as high, moderate, low, or very low. The panel updated recommendations related to initial management, ongoing management, and empiric antifungal therapy. Changes from the 2017 CPG were articulated, and good practice statements were considered. RESULTS We identified 10 new RCTs in addition to the 69 RCTs identified in previous FN CPGs to inform the 2023 FN CPG. Changes from the 2017 CPG included two conditional recommendations regarding (1) discontinuation of empiric antibacterial therapy in clinically well and afebrile patients with low-risk FN if blood cultures remain negative at 48 hours despite no evidence of marrow recovery and (2) pre-emptive antifungal therapy for invasive fungal disease in high-risk patients not receiving antimold prophylaxis. The panel created a good practice statement to initiate FN CPG-consistent empiric antibacterial therapy as soon as possible in clinically unstable febrile patients. CONCLUSION The updated FN CPG incorporates important modifications on the basis of recently published trials. Future work should focus on addressing knowledge gaps, improving CPG implementation, and measuring the impact of CPG-consistent care.
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Affiliation(s)
- Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt, Germany
| | | | - Roland A. Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Bern, Switzerland
- Kinderaerzte KurWerk, Burgdorf, Switzerland
| | - Brian Fisher
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Priya Patel
- Pediatric Oncology Group of Ontario, Toronto, Canada
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
| | - Robert Phillips
- Department of Haematology and Oncology, Leeds Teaching Hospital, NHS Trust, Leeds, United Kingdom
| | - Melissa P. Beauchemin
- Columbia University/Herbert Irving Cancer Center, Columbia University School of Nursing, New York, NY
| | - Fabianne Carlesse
- Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | | | - Andreas H. Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation, Department of Pediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany
| | - Gabrielle M. Haeusler
- Department of Infectious Diseases, Royal Children's Hospital, Melbourne, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Center, Melbourne, Australia
- NHMRC National Center for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
| | - Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Bern, Switzerland
- Kinderaerzte KurWerk, Burgdorf, Switzerland
| | - Maria E. Santolaya
- Department of Pediatrics, Hospital Dr Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Wim J.E. Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Joshua Wolf
- Division of Infectious Disease, St Jude Children's Research Hospital, Memphis, TN
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Sarah Alexander
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Helen Hu
- Pediatric Oncology Group of Ontario, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - L. Lee Dupuis
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
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45
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Navarro ML, Nieto M, Perez-Martínez A. The need for evolution in the management of febrile neutropenia in pediatric cancer: TRIIO KIDS update. Clin Transl Oncol 2023; 25:633-642. [PMID: 36244052 DOI: 10.1007/s12094-022-02971-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 09/28/2022] [Indexed: 10/17/2022]
Abstract
New treatments have increased the life expectancy of pediatric patients diagnosed with malignant hematological diseases, often at the cost of protracting their immunocompromised state in the form of prolonged neutropenia. This neutropenic state favors the development of bacterial and fungal infections. Moreover, recent years have seen a series of changes in the epidemiology of fungal and Clostridium infections. These changes necessitate adaptations to the management of pediatric patients with febrile neutropenia, who are at risk of further increases in already high rates of morbidity and mortality. This article discusses the current bases for the management of febrile neutropenia and associated emerging fungal infections, as well as the epidemiology, diagnosis, and treatment of Clostridioides difficile in pediatric patients diagnosed with malignant hematological diseases.
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Affiliation(s)
- Maria Luisa Navarro
- Department of Paediatric Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Montserrat Nieto
- Paediatric Intensive Care Unit, Hospital Infantil Niño Jesús, Madrid, Spain
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46
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Bochennek K, Hogardt M, Lehrnbecher T. Immune signatures, testing, and management of febrile neutropenia in pediatric cancer patients. Expert Rev Clin Immunol 2023; 19:267-277. [PMID: 36635981 DOI: 10.1080/1744666x.2023.2168646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Infectious complications, particularly invasive bacterial and fungal infections, are still a major cause of morbidity in pediatric cancer patients and are associated with significant mortality. Over the last few years, there has been much effort in defining risk groups to tailor antimicrobial therapy, and in establishing pediatric-specific guidelines for antimicrobial strategies. AREAS COVERED This review provides a critical overview of defining risk groups for infection, diagnostic work-up, antimicrobial prophylaxis, empirical therapy, and treatment of established infections. EXPERT OPINION To date, no generalizable risk prediction model has been established for pediatric cancer patients. There is growing interest in defining the impact of the individual genetic background on infectious complications. New diagnostic tools have been developed over the last few years, but they need to be validated in pediatric cancer patients. International, pediatric-specific guidelines for antimicrobial prophylaxis, empirical therapy, and treatment of established infections have recently been published and will harmonize antimicrobial strategies in the future.
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Affiliation(s)
- Konrad Bochennek
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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47
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Nessle CN, Braun T, Choi SW, Mody R. Internal evaluation of risk stratification tool using serial procalcitonin and clinical risk factors in pediatric febrile neutropenia: The non-interventional, single institution experience prior to clinical implementation. Pediatr Hematol Oncol 2023; 40:172-180. [PMID: 35838022 PMCID: PMC9840714 DOI: 10.1080/08880018.2022.2079785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Risk stratification of pediatric febrile neutropenia (FN) is an established concept, yet clinical risk tools misclassify nearly 5% of clinical standard-risk episodes with severe outcomes. The internal evaluation of a clinical risk tool before implementation has not been well-described. In this noninterventional cohort study, we evaluated a study decision rules (SDR) tool; a clinical risk tool with serial procalcitonin. The study standard-risk (SSR) group met clinical standard-risk criteria with two serial procalcitonin <0.4 ng/mL. The study high-risk (SHR) group met clinical high-risk criteria or clinical standard-risk with a procalcitonin ≥0.4 ng/mL. Descriptive and bivariate statistics compared the groups and outcomes. Clinical criteria alone identified 39.1% (238/608) standard-risk episodes; 5.9% (14/238) had severe events. Prospectively using the SDR, the SHR group encompassed 76.6% (92/120) of episodes; severe events occurred in 20% (3/15) of standard-risk episodes included due to elevated procalcitonin ≥0.4 ng/mL. The SHR group had more blood stream infections [21.7% (20/92) vs. 0% (0/28); P = 0.007] and intensive care admissions [13% (12/92) vs. 3.6% (1/28); P = 0.158]. In conclusion, the SDR with serial procalcitonin aided in identifying severe events in clinical standard-risk episodes, but analysis was limited. Institutions may consider similar internal evaluation methodology before FN episode risk stratification.
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Affiliation(s)
- C. N. Nessle
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - T. Braun
- School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - S. W. Choi
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - R. Mody
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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48
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Butters C, Thursky K, Hanna DT, Cole T, Davidson A, Buttery J, Haeusler G. Adverse effects of antibiotics in children with cancer: are short-course antibiotics for febrile neutropenia part of the solution? Expert Rev Anti Infect Ther 2023; 21:267-279. [PMID: 36694289 DOI: 10.1080/14787210.2023.2171987] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Febrile neutropenia is a common complication experienced by children with cancer or those undergoing hematopoietic stem cell transplantation. Repeated episodes of febrile neutropenia result in cumulative exposure to broad-spectrum antibiotics with potential for a range of serious adverse effects. Short-course antibiotics, even in patients with high-risk febrile neutropenia, may offer a solution. AREAS COVERED This review addresses the known broad effects of antibiotics, highlights developments in understanding the relationship between cancer, antibiotics, and the gut microbiome, and discusses emerging evidence regarding long-term adverse antibiotic effects. The authors consider available evidence to guide the duration of empiric antibiotics in pediatric febrile neutropenia and directions for future research. EXPERT OPINION Broad-spectrum antibiotics are associated with antimicrobial resistance, Clostridioides difficile infection, invasive candidiasis, significant disturbance of the gut microbiome and may seriously impact outcomes in children with cancer or undergoing allogenic hematopoietic stem cell transplant. Short-course empiric antibiotics are likely safe in most children with febrile neutropenia and present a valuable opportunity to reduce the risks of antibiotic exposure.
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Affiliation(s)
- Coen Butters
- Department of General Paediatrics and Adolescent Medicine, John Hunter Children's Hospital, Newcastle, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Australia.,National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, The University of Melbourne, Parkville, Australia.,Department of Medicine, The University of Melbourne, Parkville, Australia
| | - Diane T Hanna
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia
| | - Theresa Cole
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Allergy and Immunology, Royal Children's Hospital, Parkville, Australia
| | - Andrew Davidson
- Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Department of Anaesthesia, Royal Children's Hospital, Parkville, Australia.,Department of Critical Care, The University of Melbourne, Parkville, Australia.,Infectious Diseases Unit, Royal Children's Hospital, Parkville, Australia.,Melbourne Children's Trials Centre, Murdoch Children's Research Institute, Parkville, Australia
| | - Jim Buttery
- Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Infectious Diseases Unit, Royal Children's Hospital, Parkville, Australia.,Centre for Health Analytics, Melbourne Children's Campus, Parkville, Australia.,Health Informatics Group and SAEFVIC, Murdoch Children's Research Institute, Parkville, Australia
| | - Gabrielle Haeusler
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Australia.,National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, The University of Melbourne, Parkville, Australia.,Infectious Diseases Unit, Royal Children's Hospital, Parkville, Australia
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49
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Jackson K, Anderson V, Zhao Z, Kitko CL, Connelly JA, Ho RH, Banerjee R, Dulek DE, Friedman DL, Esbenshade AJ. Applying a risk prediction model for bloodstream infection in a febrile, nonseverely neutropenic cohort of pediatric stem cell transplant patients. Cancer 2023; 129:1591-1601. [PMID: 36828805 DOI: 10.1002/cncr.34703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND The optimal management of febrile stem cell transplant (SCT) patients presenting without severe neutropenia (absolute neutrophil count [ANC] ≥ 500/µL) is unclear. The authors have developed iterative risk prediction models (Esbenshade Vanderbilt [EsVan] models) that reliably predict bloodstream infections (BSIs) in the febrile general pediatric oncology population without severe neutropenia, but SCT-specific data are limited. METHODS All SCTs occurring from May 2005 to November 2019 at a single institution were identified. Episodes of fever with a central venous catheter and ANC values ≥ 500/µL were abstracted. All previous versions of the EsVan model were applied to the SCT data, and c-statistics were generated. The models were additionally applied to each type of transplant (autologous/allogeneic), and a new allogeneic model that further adjusted for metrics of immunosuppression, Esbenshade Vanderbilt Allogeneic SCT Model (EsVanAlloSCT), was developed and internally validated. RESULTS For 429 SCT episodes (221 autologous and 208 allogeneic), the BSI incidence was 19.6% (84 of 429), and it was higher in allogeneic transplant patients (25.5%) than autologous transplant patients (14.0%; p < .01). All versions of the EsVan model performed well for the overall SCT cohort (c-statistics, 0.759-0.795). The EsVan models performed better for the autologous episodes (c-statistics, 0.869-0.881) than the allogeneic SCT episodes (c-statistics, 0.678-0.717). The new allogeneic transplant-specific model, EsVanAlloSCT, which added an adjustment for the extent of immunosuppression, yielded a c-statistic of 0.792 (bootstrap-corrected, 0.750). CONCLUSIONS The EsVan models work exceptionally well when they are applied to autologous SCT, but they work less well for allogeneic SCT. EsVanAlloSCT appears to improve the predictive ability in allogeneic SCT, but it will need additional external validation.
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Affiliation(s)
- Kasey Jackson
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | | | - Zhiguo Zhao
- Department of Statistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carrie L Kitko
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - James A Connelly
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Richard H Ho
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Ritu Banerjee
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Infectious Disease, Nashville, Tennessee, USA
| | - Daniel E Dulek
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Infectious Disease, Nashville, Tennessee, USA
| | - Debra L Friedman
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Adam J Esbenshade
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
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50
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Babu S, Sreedhar R, Munaf M, Gadhinglajkar SV. Sepsis in the Pediatric Cardiac Intensive Care Unit: An Updated Review. J Cardiothorac Vasc Anesth 2023; 37:1000-1012. [PMID: 36922317 DOI: 10.1053/j.jvca.2023.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 01/25/2023] [Accepted: 02/06/2023] [Indexed: 02/13/2023]
Abstract
Sepsis remains among the most common causes of mortality in children with congenital heart disease (CHD). Extensive literature is available regarding managing sepsis in pediatric patients without CHD. Because the cardiovascular pathophysiology of children with CHD differs entirely from their typical peers, the available diagnosis and management recommendations for sepsis cannot be implemented directly in children with CHD. This review discusses the risk factors, etiopathogenesis, available diagnostic tools, resuscitation protocols, and anesthetic management of pediatric patients suffering from various congenital cardiac lesions. Further research should focus on establishing a standard guideline for managing children with CHD with sepsis and septic shock admitted to the intensive care unit.
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Affiliation(s)
- Saravana Babu
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India.
| | - Rupa Sreedhar
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India
| | - Mamatha Munaf
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India
| | - Shrinivas V Gadhinglajkar
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India
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