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Meena JP, Gupta AK. Shorter Duration of Antibiotics in Low-Risk Febrile Neutropenia in Children with Malignancy. Indian J Pediatr 2021; 88:217-218. [PMID: 33411261 DOI: 10.1007/s12098-020-03654-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 12/30/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Jagdish Prasad Meena
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Aditya Kumar Gupta
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Abstract
The management of febrile neutropenia is a backbone of treating patients with hematologic malignancies and has evolved over the past decades. This article reviews my approach to the evaluation and treatment of febrile neutropenic patients. Key topics discussed include antibacterial and antifungal prophylaxis, the initial workup for fever, the choice of the empiric antibiotic regimen and its modifications, and criteria for discontinuation. For each of these questions, I review the literature and present my perspective.
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153
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Herberger S, Oberkircher N, Wenzel GI, Hecker D, Wagenpfeil G, Furtwängler R, Becker SL, Papan C, Graf N, Simon A. [Prospektives Audit des Gentamicin Drug Monitorings in einem Kinderkrebszentrum]. KLINISCHE PADIATRIE 2021; 233:123-126. [PMID: 33601432 DOI: 10.1055/a-1352-5053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many pediatric cancer centers still use Gentamicin as first line combination treatment in patients with fever and neutropenia. Since 2011, our center has implemented a dosing regimen with 250 mg/m2 BSA (max. 10 mg/kg, max. 400 mg) as a single daily infusion according to the German guideline. PATIENTS AND METHODS In this prospective audit (February 2011 to December 2019), 105 Gentamicin treatment cycles were analyzed in 66 pediatric cancer patients, focusing on adherence to the dosing regimen and the drug monitoring results. RESULTS Adherence to the dosing regimen was high (89%). In 64% of all cycles, the Cmax (drawn 1 h after the 2nd dose) reached the target of 10-20 µg/ml. Cmax significantly correlated with dosing in mg/m2 BSA (p=0,007), but not with dosing in mg/kg (p=0,366). Age below 6 years did not influence these results. The Gentamicin Ctrough (drawn 8-10 h after the second dose) was < 2 µg/ml in 93% of all cycles without any dose correlation. None of the patients experienced Gentamicin-associated nephrotoxicity. DISCUSSION AND CONCLUSION This prospective audit of single daily infusion Gentamicin in pediatric cancer patients without impaired renal function elicits the feasibility and safety of the dosing regimen in mg/m2 BSA according to the German guideline. Since indications for first-line gentamicin are limited, a multicenter prospective study would be advantageous to confirm these observations.
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Affiliation(s)
- Sarah Herberger
- Pediatric Oncology and Hematology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Nadine Oberkircher
- Pediatric Oncology and Hematology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Gentiana I Wenzel
- Otorhinolaryngology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Dietmar Hecker
- Otorhinolaryngology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Gudrun Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Rhoikos Furtwängler
- Pediatric Oncology and Hematology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Sören L Becker
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Cihan Papan
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Norbert Graf
- Pediatric Oncology and Hematology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Arne Simon
- Pediatric Oncology and Hematology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
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154
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Olson J, Mehra S, Hersh AL, Thorell EA, Stoddard GJ, Maese L, Barnette PE, Lemons RS, Pavia AT, Knackstedt ED. Oral Step-Down Therapy With Levofloxacin for Febrile Neutropenia in Children With Cancer. J Pediatric Infect Dis Soc 2021; 10:27-33. [PMID: 32092134 DOI: 10.1093/jpids/piaa015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/03/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Although febrile neutropenia (FN) is a frequent complication in children with cancer receiving chemotherapy, there remains significant variability in selection of route (intravenous [IV] vs oral) and length of therapy. We implemented a guideline with a goal to change practice from using IV antibiotics after hospital discharge to the use of step-down oral therapy with levofloxacin for most children with FN until absolute neutrophil count > 500. The objectives of this study were to determine the impact of this guideline on home IV antibiotic use, and to evaluate the safety of implementation of this guideline. METHODS We performed a quasi-experimental, pre-post study of discharge FN treatment at a stand-alone children's hospital in patients without bacteremia discharged between January 2013 and October 2018. In January 2015, a multidisciplinary team created a guideline to switch most children with FN to oral levofloxacin, which was formally implemented as of September 2017. Discharges during the postintervention period (after September 2017) were compared to discharges in the preintervention period (between January 2013 and December 2014). RESULTS In adjusted multivariable regression analyses, the postimplementation period was associated with a decrease in home IV antibiotics (adjusted risk ratio [aRR], 0.07 [95% confidence interval {CI}, .03-.13]) and fewer IV antibiotic initiations within 24 hours of a new healthcare encounter up to 7 days after discharge (aRR, 0.39 [95% CI, .17-.93]) compared to the preintervention time period. CONCLUSIONS Step-down oral levofloxacin for children with FN who are afebrile with an ANC ≤ 500 at discharge is feasible and resulted in similar clinical outcomes compared to home IV antibiotics.
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Affiliation(s)
- Jared Olson
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, Utah, USA.,Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Sonia Mehra
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Emily A Thorell
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Gregory J Stoddard
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Luke Maese
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Phillip E Barnette
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Richard S Lemons
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Elizabeth D Knackstedt
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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155
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Stergiotis M, Ammann RA, Droz S, Koenig C, Agyeman PKA. Pediatric fever in neutropenia with bacteremia-Pathogen distribution and in vitro antibiotic susceptibility patterns over time in a retrospective single-center cohort study. PLoS One 2021; 16:e0246654. [PMID: 33577566 PMCID: PMC7880464 DOI: 10.1371/journal.pone.0246654] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/22/2021] [Indexed: 11/18/2022] Open
Abstract
Background Fever in neutropenia (FN) is a potentially life-threatening complication of chemotherapy in pediatric cancer patients. The current standard of care at most institutions is emergency hospitalization and empirical initiation of broad-spectrum antibiotic therapy. Methods We analyzed in retrospect FN episodes with bacteremia in pediatric cancer patients in a single center cohort from 1993 to 2012. We assessed the distribution of pathogens, the in vitro antibiotic susceptibility patterns, and their trends over time. Results From a total of 703 FN episodes reported, we assessed 134 FN episodes with bacteremia with 195 pathogens isolated in 102 patients. Gram-positive pathogens (124, 64%) were more common than Gram-negative (71, 36%). This proportion did not change over time (p = 0.26). Coagulase-negative staphylococci (64, 32%), viridans group streptococci (42, 22%), Escherichia coli (33, 17%), Klebsiella spp. (10, 5%) and Pseudomonas aeruginosa (nine, 5%) were the most common pathogens. Comparing the in vitro antibiotic susceptibility patterns, the antimicrobial activity of ceftriaxone plus amikacin (64%; 95%CI: 56%-72%), cefepime (64%; 95%CI 56%-72%), meropenem (64%; 95%CI 56%-72), and piperacillin/tazobactam (62%; 95%CI 54%-70%), respectively, did not differ significantly. The addition of vancomycin to those regimens would have increased significantly in vitro activity to 99% for ceftriaxone plus amikacin, cefepime, meropenem, and 96% for piperacillin/tazobactam (p < 0.001). Conclusions Over two decades, we detected a relative stable pathogen distribution and found no relevant trend in the antibiotic susceptibility patterns. Different recommended antibiotic regimens showed comparable in vitro antimicrobial activity.
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Affiliation(s)
- Melina Stergiotis
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roland A. Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Kinderaerzte Kurwerk, Burgdorf, Switzerland
| | - Sara Droz
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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156
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Abstract
Sepsis, in particular severe sepsis, is a major cause of morbidity and mortality in pediatrics. It is most likely to affect very young children and children with significant medical comorbidities. The definition of sepsis in pediatrics is currently rapidly evolving but the best treatment for children with severe sepsis remains early goal directed therapy with intravenous fluids and antibiotics. It is therefore important for any pediatric urgent care providers to be able to recognize and treat patients with severe sepsis. It is also important for pediatric urgent care providers to be aware of certain groups of patients who have an increased risk of mortality when they develop sepsis. This article summarizes the current understanding of pediatric sepsis and then focuses on the management of these patients in the pediatric urgent care setting, with special attention paid to groups at higher risks of negative outcomes.
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Affiliation(s)
- Benjamin Klick
- USADirector of Resident Education, Children's Hospital of the King's Daughters Urgent Care Division, Assistant Professor of Pediatrics, Eastern Virginia Medical School.
| | - Theresa Guins
- Director, CSG Division of Urgent Care, Medical Director, CHKD Urgent Care Services, Director, EVMS/CSG PA Urgent Care Fellowship, Associate Professor of Pediatrics, Eastern Virginia Medical School USA.
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157
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Wolf J, Abzug MJ, Wattier RL, Sue PK, Vora SB, Zachariah P, Dulek DE, Waghmare A, Olivero R, Downes KJ, James SH, Pinninti SG, Yarbrough A, Aldrich ML, MacBrayne CE, Soma VL, Grapentine SP, Oliveira CR, Hayes M, Kimberlin DW, Jones SB, Bio LL, Morton TH, Hankins JS, Marόn-Alfaro GM, Timberlake K, Young JL, Orscheln RC, Schwenk HT, Goldman DL, Groves HE, Huskins WC, Rajapakse NS, Lamb GS, Tribble AC, Lloyd EE, Hersh AL, Thorell EA, Ratner AJ, Chiotos K, Nakamura MM. Initial Guidance on Use of Monoclonal Antibody Therapy for Treatment of Coronavirus Disease 2019 in Children and Adolescents. J Pediatric Infect Dis Soc 2021; 10:629-634. [PMID: 33388760 PMCID: PMC7799019 DOI: 10.1093/jpids/piaa175] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND In November 2020, the US Food and Drug Administration (FDA) provided Emergency Use Authorizations (EUA) for 2 novel virus-neutralizing monoclonal antibody therapies, bamlanivimab and REGN-COV2 (casirivimab plus imdevimab), for the treatment of mild to moderate coronavirus disease 2019 (COVID-19) in adolescents and adults in specified high-risk groups. This has challenged clinicians to determine the best approach to use of these products. METHODS A panel of experts in pediatric infectious diseases, pediatric infectious diseases pharmacy, pediatric intensive care medicine, and pediatric hematology from 29 geographically diverse North American institutions was convened. Through a series of teleconferences and web-based surveys, a guidance statement was developed and refined based on review of the best available evidence and expert opinion. RESULTS The course of COVID-19 in children and adolescents is typically mild and there is no high-quality evidence supporting any high-risk groups. There is no evidence for safety and efficacy of monoclonal antibody therapy for treatment of COVID-19 in children or adolescents, limited evidence of modest benefit in adults, and evidence for potential harm associated with infusion reactions or anaphylaxis. CONCLUSIONS Based on evidence available as of December 20, 2020, the panel suggests against routine administration of monoclonal antibody therapy (bamlanivimab, or casirivimab and imdevimab), for treatment of COVID-19 in children or adolescents, including those designated by the FDA as at high risk of progression to hospitalization or severe disease. Clinicians and health systems choosing to use these agents on an individualized basis should consider risk factors supported by pediatric-specific evidence and ensure the implementation of a system for safe and timely administration that does not exacerbate existing healthcare disparities.
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Affiliation(s)
- Joshua Wolf
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA,Corresponding author: Dr. Joshua Wolf MBBS, PhD, FRACP, Department of Infectious Diseases, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, MS 320, Memphis, TN 38105, USA, Tel: 901 595 3300; Fax: 901 595 3099,
| | - Mark J Abzug
- Division of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Rachel L Wattier
- Division of Infectious Diseases and Global Health, Department of Pediatrics, University of California–San Francisco, San Francisco, California, USA
| | - Paul K Sue
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Surabhi B Vora
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Washington, Seattle; Children’s Hospital, Seattle, Washington, USA
| | - Philip Zachariah
- Division of Infectious Diseases, Department of Pediatrics, Columbia University, New York, New York, USA
| | - Daniel E Dulek
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University and Monroe Carell Jr. Children’s Hospital, Nashville, Tennessee, USA
| | - Alpana Waghmare
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Washington, Seattle; Children’s Hospital, Seattle, Washington, USA,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Rosemary Olivero
- Section of Infectious Diseases, Department of Pediatrics and Human Development, Helen DeVos Children’s Hospital of Spectrum Health, Michigan State College of Human Medicine, Grand Rapids, Michigan, USA
| | - Kevin J Downes
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Scott H James
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Swetha G Pinninti
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - April Yarbrough
- Department of Pharmacy, Children’s of Alabama, Birmingham, Alabama, USA
| | - Margaret L Aldrich
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital at Montefiore, New York, New York, USA
| | | | - Vijaya L Soma
- Department of Pediatrics, Division of Infectious Diseases, New York University Grossman School of Medicine and Hassenfeld Children's Hospital, New York, United States
| | - Steven P Grapentine
- Department of Pharmacy, University of California–San Francisco Benioff Children’s Hospital, San Francisco, California, USA
| | - Carlos R Oliveira
- Division of Infectious Diseases and Global Health, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, United States
| | - Molly Hayes
- Antimicrobial Stewardship Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David W Kimberlin
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sarah B Jones
- Department of Pharmacy, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Laura L Bio
- Department of Pharmacy, Lucile Packard Children’s Hospital Stanford, Palo Alto, California, USA
| | - Theodore H Morton
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Jane S Hankins
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Gabriella M Marόn-Alfaro
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Kathryn Timberlake
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer L Young
- Department of Pharmacy, St. Louis Children’s Hospital, St. Louis, Missouri, USA
| | - Rachel C Orscheln
- Division of Infectious Diseases, Department of Pediatrics, Washington University and St. Louis Children’s Hospital, St. Louis, Missouri, USA
| | - Hayden T Schwenk
- Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital Stanford, Stanford, California, USA
| | - David L Goldman
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital at Montefiore, New York, New York, USA
| | - Helen E Groves
- Division of Infectious Diseases, Department of Pediatrics,; Hospital for Sick Children, Toronto, Ontario, Canada
| | - W Charles Huskins
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Nipunie S Rajapakse
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Gabriella S Lamb
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Alison C Tribble
- Department of Pediatrics, Division of Infectious Diseases, University of Michigan and CS Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Elizabeth E Lloyd
- Department of Pediatrics, Division of Infectious Diseases, University of Michigan and CS Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Emily A Thorell
- Division of Infectious Diseases, Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Adam J Ratner
- Department of Pediatrics, Division of Infectious Diseases, New York University Grossman School of Medicine and Hassenfeld Children's Hospital, New York, United States,Department of Microbiology, New York University Grossman School of Medicine, New York, New York, USA
| | - Kathleen Chiotos
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Critical Care Medicine, Department of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mari M Nakamura
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA,Antimicrobial Stewardship Program, Boston Children’s Hospital, Boston, Massachusetts, USA,Co-Corresponding author: Mari M. Nakamura, MD, MPH, Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, 300 Longwood Avenue, Mailstop BCH 3052, Boston, MA 02115, Tel: 617 355 1561,
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158
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De Pietri S, Frandsen TL, Christensen M, Grell K, Rathe M, Müller K. Citrulline as a biomarker of bacteraemia during induction treatment for childhood acute lymphoblastic leukaemia. Pediatr Blood Cancer 2021; 68:e28793. [PMID: 33155402 DOI: 10.1002/pbc.28793] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Systemic infections are a major cause of morbidity in children with acute lymphoblastic leukaemia (ALL). However, identification of patients at increased risk is still a challenge. Knowing that both neutropaenia and gastrointestinal toxicity are risk factors for bacteraemia, we aimed at comparing absolute neutrophil counts (ANC) and plasma citrulline levels (indicating enterocyte loss) in children with ALL with and without bacteraemia during induction treatment. PROCEDURE We prospectively included 61 children with ALL treated according to the Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL-2008 protocol. ANC and plasma C-reactive protein (CRP) were measured on treatment days 1, 8, 15, 22 and 29. Plasma citrulline was measured on days 1, 8, 15 and 29. Bacteraemia episodes during induction treatment were recorded retrospectively. RESULTS Nineteen of sixty-one (31%) patients experienced bacteraemia occurring on median day 13 (range 5-20). Patients with bacteraemia during induction treatment had lower citrulline level on day 15 (P < .01) compared to patients without bacteraemia, indicating more severe enterocyte loss. Nevertheless, ANC was similar in the two patient groups on days 8 and 15. CRP was negatively correlated with same-day citrulline (P < .03 for all) and ANC (P < .04 for all). CONCLUSIONS During chemotherapy-induced neutropaenia, plasma citrulline may help identify patients at increased risk of bacteraemia.
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Affiliation(s)
- Silvia De Pietri
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mette Christensen
- Department of Clinical Genetics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kathrine Grell
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Mathias Rathe
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Klaus Müller
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Institute for Inflammation Research, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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159
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Ifversen M, Meisel R, Sedlacek P, Kalwak K, Sisinni L, Hutt D, Lehrnbecher T, Balduzzi A, Diesch T, Jarisch A, Güngör T, Stein J, Yaniv I, Bonig H, Kuhlen M, Ansari M, Nava T, Dalle JH, Diaz-de-Heredia C, Trigoso E, Falkenberg U, Hartmann M, Deiana M, Canesi M, Broggi C, Bertaina A, Gibson B, Krivan G, Vettenranta K, Matic T, Buechner J, Lawitschka A, Peters C, Yesilipek A, Yalçin K, Lucchini G, Bakhtiar S, Turkiewicz D, Niinimäki R, Wachowiak J, Cesaro S, Dalissier A, Corbacioglu S, Willasch AM, Bader P. Supportive Care During Pediatric Hematopoietic Stem Cell Transplantation: Prevention of Infections. A Report From Workshops on Supportive Care of the Paediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT). Front Pediatr 2021; 9:705179. [PMID: 34395344 PMCID: PMC8358428 DOI: 10.3389/fped.2021.705179] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/25/2021] [Indexed: 02/02/2023] Open
Abstract
Specific protocols define eligibility, conditioning, donor selection, graft composition and prophylaxis of graft vs. host disease for children and young adults undergoing hematopoietic stem cell transplant (HSCT). However, international protocols rarely, if ever, detail supportive care, including pharmaceutical infection prophylaxis, physical protection with face masks and cohort isolation or food restrictions. Supportive care suffers from a lack of scientific evidence and implementation of practices in the transplant centers brings extensive restrictions to the child's and family's daily life after HSCT. Therefore, the Board of the Pediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT) held a series of dedicated workshops since 2017 with the aim of initiating the production of a set of minimal recommendations. The present paper describes the consensus reached within the field of infection prophylaxis.
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Affiliation(s)
- Marianne Ifversen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Roland Meisel
- Division of Pediatric Stem Cell Therapy, Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Petr Sedlacek
- Department of Pediatric Hematology and Oncology, Hospital Motol, Charles University, Prague, Czechia
| | - Krzysztof Kalwak
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Luisa Sisinni
- Pediatric Hematology, Oncology and Hematopoietic Stem Cell Transplantation Unit, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Daphna Hutt
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplantation, The Edmond and Lily Safra Children's Hospital, Tel Aviv, Israel
| | - Thomas Lehrnbecher
- Division for Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Ospedale San Gerardo, Monza, Italy
| | - Tamara Diesch
- Division of Pediatric Hematology-Oncology, University Children's Hospital of Basel, Basel, Switzerland
| | - Andrea Jarisch
- Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Hospital for Children and Adolescents, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Tayfun Güngör
- Department of Hematology, Immunology, Oncology and Stem Cell Transplantation, University Children's Hospital Zürich, Zurich, Switzerland
| | - Jerry Stein
- Division of Pediatric Hematoloy-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Isaac Yaniv
- Division of Pediatric Hematoloy-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Halvard Bonig
- Institute for Transfusion Medicine and Immunohematology of Goethe University, German Red Cross Blood Service Baden-Württemberg-Hessen, Frankfurt am Main, Germany
| | - Michaela Kuhlen
- Paediatrics and Adolescent Medicine, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Marc Ansari
- Division of Pediatric Hematology-Oncology, University Hospital of Geneva, Geneva, Switzerland.,Cansearch Research Platform in Paediatric Oncology and Haematology, Department of Paediatrics, Gynaecology and Obstetrics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Tiago Nava
- Division of Pediatric Hematology-Oncology, University Hospital of Geneva, Geneva, Switzerland.,Cansearch Research Platform in Paediatric Oncology and Haematology, Department of Paediatrics, Gynaecology and Obstetrics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jean-Hugues Dalle
- Hematology and Immunology Department, Robert-Debre Hospital, Assistance Publique-Hopitaux de Paris and University of Paris, Paris, France
| | - Cristina Diaz-de-Heredia
- Department of Pediatric Oncology and Hematology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Eugenia Trigoso
- Paediatric Transplant Unit, Hospital University and Polytechnic, Hospital LA FE, Valencia, Spain
| | - Ulrike Falkenberg
- Stem Cell Transplantation-Unit, Department of Pediatrics, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Mihaela Hartmann
- Stem Cell Transplantation-Unit, Department of Pediatrics, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Marco Deiana
- Paediatric Haematology-Oncology Department, Istituto di Ricovero e Cura a Carattere Scientifico G Gaslini, Genova, Italy
| | - Marta Canesi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Ospedale San Gerardo, Monza, Italy
| | - Chiara Broggi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Ospedale San Gerardo, Monza, Italy
| | - Alice Bertaina
- Department of Pediatric Hematology-Oncology and Cell and Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Bambino Gesù, Rome, Italy.,Division of Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA, United States
| | - Brenda Gibson
- Department of Paediatric Haematology-Oncology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Gergely Krivan
- Central Hospital of Southern Pest, National Institute of Hematology and Infectious Disease, Budapest, Hungary
| | - Kim Vettenranta
- Children's Hospital and Pediatric Research Center, University of Helsinki, Helsinki, Finland
| | - Toni Matic
- Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Anita Lawitschka
- Stem Cell Transplantation-Unit, Department of Pediatrics, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Christina Peters
- Stem Cell Transplantation-Unit, Department of Pediatrics, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Akif Yesilipek
- Department of Pediatric Hematology and Pediatric Stem Cell Transplantation Unit, Antalya and Göztepe Medicalpark Hospitals, Antalya, Turkey
| | - Koray Yalçin
- Department of Pediatric Bone Marrow Transplantation Unit, Medicalpark Göztepe Hospital, Istanbul, Turkey
| | - Giovanna Lucchini
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, National Health Service Foundation Trust, London, United Kingdom
| | - Shahrzad Bakhtiar
- Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Hospital for Children and Adolescents, University Hospital, Goethe University, Frankfurt am Main, Germany
| | | | - Riitta Niinimäki
- Department of Pediatrics, Oulu University Hospital, Oulu, Finland
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Hematopoietic Stem Cell Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Arnaud Dalissier
- European Society for Blood and Marrow Transplantation Paris Office, Hôpital Saint Antoine, Paris, France
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Hospital of Regensburg, Regensburg, Germany
| | - Andre Manfred Willasch
- Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Hospital for Children and Adolescents, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Peter Bader
- Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Hospital for Children and Adolescents, University Hospital, Goethe University, Frankfurt am Main, Germany
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160
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Phillips B, Morgan JE. Meta-analytic validation of new 'AUS' febrile neutropenia risk score. Pediatr Blood Cancer 2021; 68:e28580. [PMID: 32710695 DOI: 10.1002/pbc.28580] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, UK.,Department of Paediatric Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jessica E Morgan
- Centre for Reviews and Dissemination, University of York, York, UK.,Department of Paediatric Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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161
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Zajac-Spychala O, Kampmeier S, Lehrnbecher T, Groll AH. Infectious Complications in Paediatric Haematopoetic Cell Transplantation for Acute Lymphoblastic Leukemia: Current Status. Front Pediatr 2021; 9:782530. [PMID: 35223707 PMCID: PMC8866305 DOI: 10.3389/fped.2021.782530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/15/2021] [Indexed: 12/02/2022] Open
Abstract
Haematopoietic stem cell transplantation (HSCT) in paediatric patients with acute lymphoblastic leukaemia (ALL) is associated with a variety of infectious complications which result in significant morbidity and mortality. These patients are profoundly immunocompromised, and immune reconstitution after HSCT generally occurs in astrictly defined order. During the early phase after HSCT until engraftment, patients are at risk of infections due to presence of neutropenia and mucosal damage, with Gramme-positive and Gramme-negative bacteria and fungi being the predominant pathogens. After neutrophil recovery, the profound impairment of cell-mediated immunity and use of glucocorticosteroids for control of graft-vs.-host disease (GvHD) increases the risk of invasive mould infection and infection or reactivation of various viruses, such as cytomegalovirus, varicella zoster virus, Epstein-Barr virus and human adenovirus. In the late phase, characterised by impaired cellular and humoral immunity, particularly in conjunction with chronic GvHD, invasive infections with encapsulated bacterial infections are observed in addition to fungal and viral infections. HSCT also causes a loss of pretransplant naturally acquired and vaccine-acquired immunity; therefore, complete reimmunization is necessary to maintain long-term health in these patients. During the last two decades, major advances have been made in our understanding of and in the control of infectious complications associated with HSCT. In this article, we review current recommendations for the diagnosis, prophylaxis and treatment of infectious complications following HSCT for ALL in childhood.
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Affiliation(s)
- Olga Zajac-Spychala
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
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162
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Sung L, Miller TP, Phillips R. Improving symptom control and reducing toxicities for pediatric patients with hematological malignancies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:280-286. [PMID: 33275755 PMCID: PMC7727514 DOI: 10.1182/hematology.2020000114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The continuing improvement in pediatric cancer survival over time is largely attributable to the availability of intensive therapies. Increasing attention has been focused on addressing the physical and psychosocial impacts of cancer and cancer treatments. Evidence from adult oncology suggests that routine symptom screening and feedback to health care providers can improve patient-clinician communication, reduce distress, and improve quality of life and may even increase survival. Many questions remain regarding implementation of routine symptom screening in pediatric cancer care, including the best symptom assessment instrument and the reporter type and feasibility of integration with electronic health records (EHRs). Nonsymptom adverse events are also important, for both routine clinical care and adverse event reporting for patients enrolled in clinical trials. However, traditional mechanisms for reporting adverse events lead to substantial inaccuracies and are labor intensive. An automated approach for abstraction from EHRs is a potential mechanism for improving accuracy and reducing workload. Finally, identification of symptom and nonsymptom toxicities must be paired with prophylactic and therapeutic strategies. These strategies should be based on clinical practice guidelines that synthesize evidence and use multiprofessional, multidisciplinary expertise to place this evidence in clinical context and create recommendations. How best to implement clinical practice guidelines remains a challenge, but EHR order sets and alerts may be useful. In summary, although survival is excellent for pediatric patients receiving cancer therapies, more focus is needed on identification of symptoms and nonsymptom toxicities and their management. The EHR may be useful for promoting better supportive care through these mechanisms.
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Affiliation(s)
| | - Tamara P. Miller
- Children’s Healthcare of Atlanta, Emory University, Atlanta, GA; and
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
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163
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Buus-Gehrig C, Bochennek K, Hennies MT, Klingebiel T, Groll AH, Lehrnbecher T. Systemic viral infection in children receiving chemotherapy for acute leukemia. Pediatr Blood Cancer 2020; 67:e28673. [PMID: 32918533 DOI: 10.1002/pbc.28673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/25/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
Systemic viral diseases frequently occur in allogeneic hematopoietic stem cell transplantation, but data in children receiving chemotherapy for acute leukemia are scarce. We therefore collected and analyzed the published data on symptomatic infection from cytomegalovirus, herpes simplex virus, varicella zoster virus, parvovirus B19, or adenovirus in pediatric acute leukemia. Reports on 68 children were identified, of whom 16 patients have died from the infection. Further studies have to (1) evaluate the true incidence of these infections in pediatric acute leukemia, (2) their impact on outcome, and (3) whether a subpopulation of patients could benefit from screening and prophylactic strategies.
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Affiliation(s)
- Constanze Buus-Gehrig
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Konrad Bochennek
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Marc T Hennies
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - Thomas Klingebiel
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
| | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
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164
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Thangthong J, Anugulruengkitt S, Lauhasurayotin S, Chiengthong K, Poparn H, Sosothikul D, Techavichit P. Predictive Factors of Severe Adverse Events in Pediatric Oncologic Patients with Febrile Neutropenia. Asian Pac J Cancer Prev 2020; 21:3487-3492. [PMID: 33369443 PMCID: PMC8046322 DOI: 10.31557/apjcp.2020.21.12.3487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Febrile neutropenia (FN) is severe and potentially life-threatening in oncologic patients. The objective of this study is to define the factors associated with severe adverse outcomes of pediatric FN. METHODS A retrospective and prospective descriptive study performed in pediatric patients diagnosed with FN at King Chulalongkorn Memorial Hospital from January 2013 to December 2017. Severe adverse events defined as the presence in one of these following oxygen therapies, mechanical ventilator, shock, admission to ICU, renal dysfunction, and liver dysfunction. RESULTS The study included 267 patients with 563 febrile neutropenia episodes. The median (range) age was 5.1 years (1 month-15 year). Among 563 febrile neutropenia episodes, 115 episodes (20%) developed severe adverse events. The FN patients were classified into low and high-risk groups, 91% of patients with severe adverse events and all 21 patients who died were in high risk group. The overall mortality rate was 3.1%. Factors associated with severe adverse events were fungal infection (aOR 6.51, 95%CI 2.29-18.56), central venous catheter insertion (aOR 4.28, 95% CI 2.51-7.29), CPG defined high risk (aOR 3.35, 95%CI 1.56-7.17), viral infection (aOR 2.72, 95%CI 1.05-7.06), lower respiratory tract infection (aOR 2.52, 95%CI 1.09-5.82) and treatment not according to CPG (aOR 2.47, 95% CI 1.51-4.03). CONCLUSIONS Fungal and viral infection, central venous catheter insertion, lower respiratory tract infection, CPG defined high risk and treatment not according to CPG were associated factors of increased risk for severe adverse events. Our current institutional CPG for FN in children was applicable and improved clinical outcomes for this group of patients. <br />.
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Affiliation(s)
- Jutarat Thangthong
- Department of Pediatrics, Faculty of Medicine, King Chulalongkorn Memorial hospital, Chulalongkorn University, Bangkok, Thailand
| | - Suvaporn Anugulruengkitt
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Supanun Lauhasurayotin
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,STAR Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kanhatai Chiengthong
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,STAR Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Hansamon Poparn
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,STAR Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Darintr Sosothikul
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,STAR Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Piti Techavichit
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,STAR Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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165
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Resistance to Antibiotics of Uropathogen Bacteria Isolated From Urine and Blood in Pediatric Cancer Patients: A Single Center, 12-year Study. Pediatr Infect Dis J 2020; 39:1106-1110. [PMID: 33021597 DOI: 10.1097/inf.0000000000002854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Resistant pathogens have become a major healthcare problem in children with cancer, causing different kinds of infections such as the bloodstream ones, most common, and most frequently described and the urinary tract ones, of which less data are available. We analyzed and compared the proportions, and the trends of resistance in pathogens isolated from blood and urines in children with cancer followed in IRCCS Istituto Giannina Gaslini, Genova, Italy, from January 2007 to December 2018. Overall, 345 strains detected in urines and 282 in bloodstream infections were analyzed. Enterobacteriales were the most frequently isolated pathogens. During the study period in urines, there was a significant increase of resistance to ceftazidime, ciprofloxacin, piperacillin/tazobactam, and trimethoprim-sulfamethoxazole, but pathogens from blood were significantly more frequently resistant to amikacin, piperacillin/tazobactam, and combination therapy piperacillin/tazobactam+amikacin, even if with a decreasing trend during the study period. These data confirm the importance of surveillance of isolated microorganism and antibiotic resistance in cancer children.
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166
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Trends of Pediatric Bloodstream Infections in Stockholm, Sweden: A 20-year Retrospective Study. Pediatr Infect Dis J 2020; 39:1069-1074. [PMID: 32773664 DOI: 10.1097/inf.0000000000002850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The etiology of bloodstream infections (BSIs) changes over time due to updated immunization programs, new antibiotic-use strategies, changes in patient mix and travel. Continuous surveillance can guide empiric therapy and identify targets for prevention. METHOD We conducted a descriptive retrospective analysis among children <18 years of age who were detected with BSI between July 1998 and June 2018 for changes in the incidence, risk factors, and etiology of BSI in a Swedish tertiary hospital (Karolinska University Hospital). RESULTS We evaluated 2079 episodes of BSI. During the study period, the incidence of BSI in children 0-17 years of age decreased (τ = -0.45, P = 0.016), which was most evident among children 3 months to 2 years of age (τ = -0.59, P = 0.0006) and in early neonatal period (0-7 days; τ = -0.44, P = 0.0069). These were explained by the reduced occurrence of Streptococcus pneumoniae in children 3 months to 2 years of age and Streptococcus agalactiae and Candida spp. in neonates. Staphylococcus aureus was the commonest pathogen, accounting for 31.6% of episodes. The proportion of hospital-acquired infection was higher in patients with underlying risk factors (47.6% vs. 2.6%). The etiology of hospital-acquired infection BSI was more diverse than that of community-acquired infections and was related to underlying risk factors. The crude mortality rate was 5.7%. For children admitted to the neonatal ward, the mortality was 17.6%, but declined (τ = -0.469, P = 0.004) over the study period. CONCLUSIONS There was a decreasing trend of pediatric BSI and mortality over last 20 years, which was associated with pneumococcal immunization and antimicrobial prophylaxis for high-risk patients.
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167
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Kobayashi R, Sano H, Matsushima S, Hori D, Yanagi M, Kodama K, Suzuki D, Kobayashi K. Meropenem versus piperacillin/tazobactam for febrile neutropenia in pediatric patients: efficacy of piperacillin/tazobactam as a 1-h drip infusion four times a day. Int J Hematol 2020; 113:430-435. [PMID: 33170417 DOI: 10.1007/s12185-020-03031-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 11/28/2022]
Abstract
Although survival of children with hematological diseases and cancer has increased dramatically, febrile neutropenia (FN) is a frequently observed complication and is sometimes life-threatening in pediatric cancer patients. A prospective, randomized study was performed to clarify the usefulness of meropenem (MEPM) and piperacillin/tazobactam (PIPC/TAZ) for pediatric patients with FN. Ninety-nine patients with 394 episodes were randomly assigned to receive MEPM or PIPC/TAZ. MEPM was administered at 120 mg/kg/day as a 1-h drip infusion 3 times a day. On the other hand, PIPC/TAZ was administered at 360 mg/kg/day as a 1-h drip infusion 4 times a day. MEPM was effective in 69.5% of the 200 episodes, and PIPC/TAZ was effective in 77.2% of the 193 episodes. Compared with our previous study of MEPM 120 mg/kg/day as a 1-h drip infusion 3 times a day versus PIPC/TAZ 337.5 mg/kg/day as a 1-h drip infusion 3 times a day, the success rate of the MEPM group was not different. However, the success rate of the PIPC/TAZ group was higher than in the previous study (p = 0.001). In particular, the success rate in patients ≥ 15 years of age was improved in the PIPC/TAZ group of the present study compared with the previous study (p = 0.005).
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Affiliation(s)
- Ryoji Kobayashi
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, 6-6 Higashi-Sapporo, Shiroishiku, Sapporo, 003-0006, Japan.
| | - Hirozumi Sano
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, 6-6 Higashi-Sapporo, Shiroishiku, Sapporo, 003-0006, Japan
| | - Satoru Matsushima
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, 6-6 Higashi-Sapporo, Shiroishiku, Sapporo, 003-0006, Japan
| | - Daiki Hori
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, 6-6 Higashi-Sapporo, Shiroishiku, Sapporo, 003-0006, Japan
| | - Masato Yanagi
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, 6-6 Higashi-Sapporo, Shiroishiku, Sapporo, 003-0006, Japan
| | - Koya Kodama
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, 6-6 Higashi-Sapporo, Shiroishiku, Sapporo, 003-0006, Japan
| | - Daisuke Suzuki
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, 6-6 Higashi-Sapporo, Shiroishiku, Sapporo, 003-0006, Japan
| | - Kunihiko Kobayashi
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, 6-6 Higashi-Sapporo, Shiroishiku, Sapporo, 003-0006, Japan
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168
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Lages PM, Carlesse F, Boettger BC, Pignatari ACC, Petrilli AS, de Moraes-Pinto MI. Invasive pneumococcal disease in children with cancer: Incidence density, risk factors and isolated serotypes. Braz J Infect Dis 2020; 24:489-496. [PMID: 33164827 PMCID: PMC9392108 DOI: 10.1016/j.bjid.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/09/2020] [Accepted: 09/18/2020] [Indexed: 11/30/2022] Open
Abstract
Background Pediatric oncology patients (POP) have a high risk of infections due to impaired immunity. Invasive pneumococcal disease (IPD) is an important cause of severe infection in these patients and it is associated with high mortality. This study aimed to evaluate the incidence and risk factors associated with IPD at a Pediatric Oncology Center in Brazil. Methods This was a retrospective case-control study. All IPD cases in children with cancer from 2005 through 2016 were reviewed. Each case of IPD was matched with two controls from a cohort of patients matched for year of IPD, age and disease in order to assess risk factors. The incidence density was calculated as the number of IPD per 100,000 patients-year. Results A total of 51 episodes of IPD in 49 patients was identified. All pneumococci were isolated from blood cultures. The median age was five years and 67% were male; mortality rate was 7.8%. The IPD incidence density rate in POP was 311.21 per 100,000 patients-year, significantly higher than the rate in the general pediatric population. Severe neutropenia was the only risk factor associated with IPD, after multivariate conditional logistic regression analysis. Conclusion Although pneumococcal disease decreased after the introduction of 10-valent pneumococcal vaccine in the Brazilian national immunization schedule in 2010, there was no decrease in the IPD incidence rate in our cohort. A higher coverage rate of pneumococcal vaccination in children in the general population might be necessary to reduce the incidence rate in this high-risk population.
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169
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Meropenem to Children With Febrile Neutropenia Induces Monoresistant Pseudomonas aeruginosa. J Pediatr Hematol Oncol 2020; 42:e783-e787. [PMID: 31972720 DOI: 10.1097/mph.0000000000001713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Antimicrobial resistance in Pseudomonas aeruginosa is a threat to children with cancer. We explored the association between P. aeruginosa resistance and previous antibiotic exposure. All children with cancer and P. aeruginosa bacteremia in 2007 to 2016 in Denmark, a country with an overall resistance rate of ∼3%, were included. Twenty percent (10/49) of isolates from children previously exposed to meropenem were meropenem nonsusceptible. The only significant risk factor of meropenem nonsusceptibility was previous meropenem therapy (P=0.03). On the basis of these results, we suggest that meropenem should be reserved as a last resort for children with febrile neutropenia in countries with low antimicrobial resistance.
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170
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Outcomes of Febrile Neutropenia in Children With Cancer Managed on an Outpatient Basis: A Report From Tertiary Care Hospital From a Resource-limited Setting. J Pediatr Hematol Oncol 2020; 42:467-473. [PMID: 32815874 DOI: 10.1097/mph.0000000000001896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In low-risk febrile neutropenia (FN) patients, outpatient management is now an accepted treatment, but there is a scarcity of data on high-risk patients. The aim of our study was to describe the outcome of FN treated primarily in an outpatient setting on the basis of the severity of illness at presentation, irrespective of the intensity of chemotherapy, and absolute neutrophil count. In this prospective study, not severely ill (NSI) patients were treated with empiric antibiotics at the daycare center (outpatient) and were admitted subsequently if there was persistent fever or any complication arose. Severely ill (SI) children were admitted to the hospital upfront. A total of 118 FN episodes among children with cancer on chemotherapy 18 years of age and younger were studied. Among NSI patients managed as outpatients (n=103), 89 patients (86%) recovered with outpatient treatment, and 14 patients required hospitalization after the median duration of 5 days (interquartile range: 4 to 6 d) of antibiotic therapy. The main indication for hospital admission in the SI group was hypotension (n=5), and in the NSI group, it was persistent fever (n=11). Overall, 5% of patients (6/118) died, and 2 of these were in the NSI group. The results of this study suggest that carefully selected NSI patients could be successfully treated at outpatient management in resource-poor settings and subsequent admission if warranted.
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171
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Bravo AM, Arango J, Ramirez O, Portilla CA, López P, Calle JP, López-Medina E. Infectious complications after allogeneic hematopoietic stem cell transplantation in children in a bone marrow transplant unit in Colombia. Transpl Infect Dis 2020; 23:e13498. [PMID: 33119920 DOI: 10.1111/tid.13498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/05/2020] [Accepted: 10/18/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There is a relative lack of information about infections occurring in children following allogeneic hematopoietic stem cell transplants (allo-HSCT) in developing countries. Herein, we describe the incidence rates of different infections according to the transplant period and baseline condition in Colombia. METHODS In a retrospective cohort study of all children who underwent allo-HSCTs from 2012 to 2017 in a hospital in Cali, Colombia, we reviewed medical records from the first post-transplant day until day + 365 to describe microbiologically confirmed incidence rates of infections and deaths during three post-transplant periods and according to baseline condition. RESULTS Most allo-HSCT (n = 144, 96%) were followed by infections over the following year, mostly due to bacteria and cytomegalovirus (4.3 and 3.3 per 1000 patient-days, respectively). Children were at the highest risk for infection in the first 30 days post-HSTC, but mortality was highest after 100 days. Overall, high mortality (n = 44, 31.7%) was associated with infections, especially from extensively drug-resistant bacteria, adenovirus, and aspergillosis. Infection rates were similar independent of the baseline condition. CONCLUSION Almost all children in this cohort developed infections post allo-HSCT. Describing the distribution of infections throughout the first post allo-HSCT year allows clinicians to narrow the differential diagnosis of infections according to the post-transplant period. This is especially useful when prioritizing interventions in children receiving HSCT in stringent healthcare systems in developing countries.
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Affiliation(s)
- Ana Milena Bravo
- Universidad del Cauca, Popayán, Colombia.,Hospital Universitario San José, Popayán, Colombia.,Clínica Nueva, Cali, Colombia
| | - Jailer Arango
- Departamento de Pediatría, Universidad del Valle, Cali, Colombia.,Unidad Maternoinfantil del Tolima, Clínica Medicadiz, Ibagué, Colombia
| | - Oscar Ramirez
- Registro Poblacional de Cáncer de Cali, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Carlos Andres Portilla
- Departamento de Pediatría, Universidad del Valle, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Pio López
- Departamento de Pediatría, Universidad del Valle, Cali, Colombia.,Centro de Estudios en Infectología Pediátrica, Cali, Colombia
| | - Juan Pablo Calle
- Centro de Estudios en Infectología Pediátrica, Cali, Colombia.,Departamento de Pediatría, Universidad del Quindío, Armenia, Colombia
| | - Eduardo López-Medina
- Departamento de Pediatría, Universidad del Valle, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia.,Centro de Estudios en Infectología Pediátrica, Cali, Colombia
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172
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Patel B, Noda A, Godbout E, Stevens M, Noda C. Levofloxacin for Antibacterial Prophylaxis in Pediatric Patients With Acute Myeloid Leukemia or Undergoing Hematopoietic Stem Cell Transplantation. J Pediatr Pharmacol Ther 2020; 25:629-635. [PMID: 33041718 DOI: 10.5863/1551-6776-25.7.629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study aimed to evaluate the use of levofloxacin for the prevention of bacterial infections in pediatric patients with acute myeloid leukemia or those undergoing hematopoietic stem cell transplantation. METHODS This study was a single-center, retrospective review designed to assess the frequency of bacteremia with levofloxacin prophylaxis compared with historical controls that used other, clinician-directed antibacterial prophylaxis. The primary outcome of the study was microbiologically documented bacteremia. Secondary outcomes included febrile neutropenia, clinically documented infection, duration of neutropenia, treatment antibiotic exposure days, Clostridioides difficile infection, and infection-related mortality. RESULTS Of the 60 patients included, 24 patients with 32 hospital admissions received levofloxacin and 36 patients with 48 hospital admissions received clinician-directed prophylaxis. There was no difference found in the frequency of bacteremia between levofloxacin and clinician-directed prophylaxis (15.6% vs 10.4%, p = 0.49). There was no difference in the incidence of febrile neutropenia, clinically documented infection, treatment antibiotic exposure days, or 30-day infection-related mortality between the 2 groups. The levofloxacin group had a longer mean duration of neutropenia compared with clinician-directed prophylaxis (26.8 days vs 16.4 days, p = 0.01). CONCLUSIONS There was no difference in bacteremia between levofloxacin prophylaxis and clinician-directed prophylaxis in pediatric patients with acute myeloid leukemia or those undergoing hematopoietic stem cell transplantation. Levofloxacin prophylaxis is an appropriate alternative for the prevention of serious bacterial infections in this patient population, although further studies are needed to confirm these results.
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173
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Maser B, Pelland-Marcotte MC, Alexander S, Sung L, Gupta S. Levofloxacin prophylaxis in hospitalized children with leukemia: A cost-utility analysis. Pediatr Blood Cancer 2020; 67:e28643. [PMID: 32785971 DOI: 10.1002/pbc.28643] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Infections are common and are a major cause of morbidity and mortality during treatment of childhood leukemia. We evaluated the cost effectiveness of levofloxacin antibiotic prophylaxis, compared to no prophylaxis, in children receiving chemotherapy for acute myeloid leukemia (AML) or relapsed acute lymphoblastic leukemia (ALL). PROCEDURES A cost-utility analysis was conducted from the perspective of the single-payer health care system using a lifetime horizon. A comprehensive literature review identified available evidence for effectiveness, safety, costs of antibiotic prophylaxis in children with leukemia, and health utilities associated with the relevant health states. The effects of levofloxacin prophylaxis on health outcomes, quality-adjusted life-years (QALY), and direct health costs were derived from a combined decision tree and state-transition model. One-way deterministic and probabilistic sensitivity analyses were performed to test the sensitivity of results to parameter uncertainty. RESULTS The literature review revealed one randomized controlled trial on levofloxacin prophylaxis in childhood AML and relapsed ALL, by Alexander et al, that showed a significant reduction in rates of fever and neutropenia (71.2% vs 82.1%) and bacteremia (21.9% vs 43.4%) with levofloxacin compared to no prophylaxis. In our cost-utility analysis, levofloxacin prophylaxis was dominant over no prophylaxis, resulting in cost savings of $542.44 and increased survival of 0.13 QALY. In probabilistic sensitivity analysis, levofloxacin prophylaxis was dominant in 98.8% of iterations. CONCLUSIONS The present analysis suggests that levofloxacin prophylaxis, compared to no prophylaxis, is cost saving in children receiving intensive chemotherapy for AML or relapsed ALL.
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Affiliation(s)
- Brandon Maser
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Marie-Claude Pelland-Marcotte
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,CHU de Québec - Centre Mère-Enfant Soleil, Quebec City, Quebec, Canada
| | | | - Lillian Sung
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Sumit Gupta
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
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174
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Cefepime Versus Cefepime Plus Amikacin as an Initial Antibiotic Choice for Pediatric Cancer Patients With Febrile Neutropenia in an Era of Increasing Cefepime Resistance. Pediatr Infect Dis J 2020; 39:931-936. [PMID: 32453199 DOI: 10.1097/inf.0000000000002751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND We investigated the treatment outcomes before and after the addition of amikacin to cefepime monotherapy as an initial empirical antibiotic treatment in pediatric cancer patients with febrile neutropenia. METHODS This was a retrospective historical cohort study. The subjects were pediatric cancer patients who visited the emergency room at the Samsung Medical Center, Seoul, Korea, due to chemotherapy-induced febrile neutropenia, between January 2011 and December 2016. Since September 2014, the empirical antimicrobial treatment regimen for febrile neutropenia was changed from high-dose cefepime monotherapy to combination therapy of adding a single dose of amikacin. RESULTS Two hundred twenty-five bacteremia episodes in 164 patients were reported during the study period. Bacteremia caused by cefepime-resistant Gram-negative bacteria was observed in 16% of patients before September 2014 and in 21% of the patients after September 2014 (P = 0.331). Use of appropriate empirical antibiotic treatments increased from 62% to 83% following addition of amikacin to cefepime treatment (P = 0.003). The duration of fever was shorter in the cefepime plus amikacin group than in the cefepime group (22 vs. 34 hours, P = 0.014); however, rates of septic shock and pediatric intensive care unit hospitalizations were not significantly different between the 2 groups (septic shock, both 7%, P = 0.436; pediatric intensive care unit 3% vs. 1%, P = 0.647). CONCLUSIONS We observed no additional benefit of amikacin addition to high-dose cefepime monotherapy. Therefore, adding amikacin to cefepime monotherapy in conditions where cefepime-resistant Gram-negative bacteremia amounts to 20% or less may not be justified.
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175
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Esbenshade AJ, Zhao Z, Baird A, Holmes EA, Dulek DE, Banerjee R, Friedman DL. Prospective Implementation of a Risk Prediction Model for Bloodstream Infection Safely Reduces Antibiotic Usage in Febrile Pediatric Cancer Patients Without Severe Neutropenia. J Clin Oncol 2020; 38:3150-3160. [PMID: 32762614 DOI: 10.1200/jco.20.00591] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Management of febrile pediatric patients with cancer with an absolute neutrophil count of 500/µL or greater is unclear. The Esbenshade Vanderbilt (EsVan) risk prediction models have been shown to predict bloodstream infection (BSI) likelihood in this population, and this study sought to prospectively validate and implement these models in clinical practice. METHODS Data were prospectively collected on febrile pediatric patients with cancer with a central venous catheter from April 2015 to August 2019 at a single site, at which the models (EsVan: 2015 to 2017; EsVan2: October 2017 to 2019) were initially developed and subsequently implemented for clinical management in well-appearing nonseverely neutropenic individuals. It was recommended that patients with low BSI risk (< 10%) be discharged home without antibiotics, those with intermediate BSI risk (10%-39.9%) be administered an antibiotic before discharge, and those with high BSI risk (> 40%) be admitted on broad-spectrum antibiotics. Seven-day outcomes were then collected and EsVan models were prospectively validated and C-statistics estimated. RESULTS In 937 febrile, nonsevere neutropenia episodes, frequencies of low-, intermediate-, and high-risk episodes were 88.9%, 8.6%, and 2.3% respectively. BSI incidence was 4.2% (39 of 937). Within risk groups, low-risk BSI incidence was 1.9% (16 of 834) with BSI incidence of 13.6% and 54.5% for intermediate- and high-risk episodes, respectively. Empirical intravenous antibiotics were administered in 21.1% of low-risk episodes at presentation and at 7 days postpresentation, 72.3% of episodes never required intravenous antibiotics. There were no deaths or clinical decompensations attributable to antibiotic delay. For BSI detection, EsVan and EsVan2 models applied to the new cohort achieved C-statistics of 0.802 and 0.824, respectively. CONCLUSION Prospective, real-time clinical utilization of the EsVan models accurately predicts BSI risk and safely reduces unnecessary antibiotic use in febrile, nonseverely neutropenic pediatric patients with cancer.
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Affiliation(s)
- Adam J Esbenshade
- Vanderbilt University School of Medicine, Nashville, TN.,Vanderbilt-Ingram Cancer Center, Nashville, TN.,Division of Pediatric Hematology-Oncology, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Alaina Baird
- Division of Pediatric Hematology-Oncology, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | | | - Daniel E Dulek
- Vanderbilt University School of Medicine, Nashville, TN.,Division of Pediatric Infectious Disease, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Ritu Banerjee
- Vanderbilt University School of Medicine, Nashville, TN.,Division of Pediatric Infectious Disease, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Debra L Friedman
- Vanderbilt University School of Medicine, Nashville, TN.,Vanderbilt-Ingram Cancer Center, Nashville, TN.,Division of Pediatric Hematology-Oncology, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
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176
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McMullan BJ, Haeusler GM, Hall L, Cooley L, Stewardson AJ, Blyth CC, Jones CA, Konecny P, Babl FE, Mechinaud F, Thursky K. Aminoglycoside use in paediatric febrile neutropenia - Outcomes from a nationwide prospective cohort study. PLoS One 2020; 15:e0238787. [PMID: 32936822 PMCID: PMC7494114 DOI: 10.1371/journal.pone.0238787] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/22/2020] [Indexed: 11/18/2022] Open
Abstract
Aminoglycosides are commonly prescribed to children with febrile neutropenia (FN) but their impact on clinical outcomes is uncertain and extent of guideline compliance is unknown. We aimed to review aminoglycoside prescription and additional antibiotic prescribing, guideline compliance and outcomes for children with FN. We analysed data from the Australian Predicting Infectious ComplicatioNs in Children with Cancer (PICNICC) prospective multicentre cohort study, in children <18 years with FN between November 2016 and January 2018. Impact of aminoglycoside use in the first 12 hours of FN on composite unfavourable outcome of death, ICU admission, relapse of infection or late-onset sepsis was assessed using multivariable Cox regression. The study was conducted in Australia where antimicrobial resistance among gram negative organisms is relatively low. Data from 858 episodes of FN in 462 children from 8 centres were assessed, median age 5.8 years (IQR 3.5-10.8 years). Early empiric aminoglycosides were prescribed in 255 episodes (29.7%). Guideline non-compliance was common: in 46% (184/400) of eligible episodes, patients did not receive aminoglycosides, while aminoglycosides were prescribed in 9% (39/458) of guideline-ineligible episodes. Adjusted hazard of the composite unfavourable outcome was 3.81 times higher among patients prescribed empiric aminoglycosides than among those who weren't (95% confidence interval, 1.89-7.67), with no increased risk of unfavourable outcome in eligible patients who did not receive aminoglycosides. In a large paediatric FN cohort, aminoglycoside prescription was common and was often non-compliant with guidelines. There was no evidence for improved outcome with aminoglycosides, even in those who met guideline criteria, within a low-resistance setting. Empiric aminoglycoside prescription for children with FN requires urgent review in guidelines and in national practice.
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Affiliation(s)
- Brendan J. McMullan
- NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia
- Department of Immunology and Infectious Diseases, Sydney Children’s Hospital, Randwick, Sydney, NSW, Australia
- School of Women’s and Children’s Health, University of New South Wales, Sydney, NSW, Australia
- * E-mail:
| | - Gabrielle M. Haeusler
- NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- The Paediatric Integrated Cancer Service, Parkville, Victoria, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children’s Hospital, Parkville, Victoria, Australia
- Infection and Immunity Theme, The Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Lisa Hall
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - Louise Cooley
- Department of Microbiology and Infectious Diseases, Department of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Andrew J. Stewardson
- Department of Infectious Diseases, The Alfred and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Christopher C. Blyth
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- Department of Paediatric Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
- Department of Microbiology, PathWest Laboratory Medicine, QEII Medical Centre, Perth, Western Australia, Australia
| | - Cheryl A. Jones
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Sydney Children’s Hospital Network–The Children’s at Westmead, Westmead, NSW, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Pamela Konecny
- Department of Infectious Diseases, Immunology & Sexual Health, St George Hospital, Sydney, NSW, Australia
- St George & Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Franz E. Babl
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Department of Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
| | - Françoise Mechinaud
- Royal Children's Hospital, Parkville, Victoria, Australia
- Hôpital Robert Debré APHP Nord-Université de Paris, Paris, France
| | - Karin Thursky
- NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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177
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Martinez MF, Alveal E, Soto TG, Bustamante EI, Ávila F, Bangdiwala SI, Flores I, Benavides C, Morales R, Varela NM, Quiñones LA. IL-6 -572C>G and CARD8 304T>A Genetic Polymorphisms are Associated with the Absolute Neutrophil Count in Patients with Hematological Malignancies Under Chemotherapy: An Application of Multilevel Models to a Preliminary Pharmacogenetic Study. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2020; 13:337-343. [PMID: 32922063 PMCID: PMC7450656 DOI: 10.2147/pgpm.s261208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/02/2020] [Indexed: 01/06/2023]
Abstract
Purpose Neutropenia is a common event in patients undergoing cytotoxic chemotherapy for the treatment of a hematological malignancy. Some polymorphisms, as IL-6 -572C>G (rs1800796), IL-1β -31 G>A (rs1143627), and CARD8 304T>A (rs2043211), in genes related to the inflammatory process, could affect the level of absolute neutrophil count (ANC) after chemotherapy. Since an efficient inflammatory process enhances neutrophil survival, we hypothesize that these polymorphisms are associated with ANC. Patients and Methods We carried out a prospective cohort study in two hospitals in Santiago, Chile. The patients included were adults diagnosed with acute myeloblastic leukemia, acute lymphoblastic leukemia, or non-Hodgkin's lymphoma, undergoing cytotoxic chemotherapy. We use a multilevel linear regression model to test our hypothesis. The best model was selected using the Akaike's information criterion (AIC). Results We analyzed 1726 hemograms and ANCs from 172 hospitalizations from 32 patients. The results show that CC and CG genotypes of IL-6 -572 C>G polymorphism are associated with higher ANCs compared with the GG genotype (Ln (ANC) ~ 0.81 IC95% 0.02-1.55). Similarly, TT and AT genotypes of CARD8 304T>A polymorphism were related to higher ANCs compared with AA (Ln (ANC) ~ 0.95 IC95% 0.02-1.82). IL-1β genetic polymorphism had no statistically significant association with ANC. Conclusion IL-6 rs1800796 -572C>G and CARD8 rs2043211 304T>A polymorphisms are associated with the absolute neutrophil count in patients undergoing cytotoxic chemotherapy for treatment of hematological malignancies. Our findings might be useful to improve the safety of chemotherapy through predictive ANC models.
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Affiliation(s)
- Matias F Martinez
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics (CQF), Department of Basic and Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile.,Latin American Network for the Implementation and Validation of Pharmacogenomic Clinical Guidelines (RELIVAF-CYTED), Madrid, Spain
| | - Enzo Alveal
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics (CQF), Department of Basic and Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile
| | - Tomas G Soto
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics (CQF), Department of Basic and Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile.,Departamento De Ciencias Básicas Santiago, Facultad De Ciencias, Universidad Santo Tomás, Santiago, Chile
| | | | - Fernanda Ávila
- Infectology Section, Medicine Department, Clinical Hospital of the University of Chile, Santiago, Chile
| | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ivonne Flores
- Cancer Institute Arturo López Pérez Foundation, Santiago, Chile
| | | | - Ricardo Morales
- Cancer Institute Arturo López Pérez Foundation, Santiago, Chile
| | - Nelson M Varela
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics (CQF), Department of Basic and Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile.,Latin American Network for the Implementation and Validation of Pharmacogenomic Clinical Guidelines (RELIVAF-CYTED), Madrid, Spain
| | - Luis A Quiñones
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics (CQF), Department of Basic and Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile.,Latin American Network for the Implementation and Validation of Pharmacogenomic Clinical Guidelines (RELIVAF-CYTED), Madrid, Spain
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178
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Ramamoorthy JG, Radhakrishnan V, Ganesan P, Dhanushkodi M, Ganesan T, Sagar T. Malnutrition is a predisposing factor for developing recurrent fever following febrile neutropenia in children with acute lymphoblastic leukemia. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2020. [DOI: 10.1016/j.phoj.2020.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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179
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Evaluation of an empiric antibiotic regimen in pediatric oncology patients presenting with fever does not reveal the emergence of antibiotic resistance over a 12-year period. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2020. [DOI: 10.1016/j.phoj.2020.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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180
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Pulmonary Infectious Complications in Children with Hematologic Malignancies and Chemotherapy-Induced Neutropenia. Diseases 2020; 8:diseases8030032. [PMID: 32824956 PMCID: PMC7564221 DOI: 10.3390/diseases8030032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/04/2020] [Accepted: 08/17/2020] [Indexed: 11/16/2022] Open
Abstract
Infections frequently complicate the treatment course in children with hematologic malignancies undergoing chemotherapy. Febrile neutropenia (FN) remains a major cause of hospital admissions in this population, and respiratory tract is often proven to be the site of infection even without respiratory signs and symptoms. Clinical presentation may be subtle due to impaired inflammatory response. Common respiratory viruses and bacteria are widely identified in these patients, while fungi and, less commonly, bacteria are the causative agents in more severe cases. A detailed history, thorough clinical and basic laboratory examination along with a chest radiograph are the first steps in the evaluation of a child presenting signs of a pulmonary infection. After stratifying patient’s risk, prompt initiation of the appropriate empirical antimicrobial treatment is crucial and efficient for the majority of the patients. High-risk children should be treated with an intravenous antipseudomonal beta lactam agent, unless there is suspicion of multi-drug resistance when an antibiotic combination should be used. In unresponsive cases, more invasive procedures, including bronchoalveolar lavage (BAL), computed tomography (CT)-guided fine-needle aspiration or open lung biopsy (OLB), are recommended. Overall mortality rate can reach 20% with higher rates seen in cases unresponsive to initial therapy and those under mechanical ventilation.
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181
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[Serious adverse events associated with chemotherapy in children with acute lymphoblastic leukemia]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22. [PMID: 32800028 PMCID: PMC7441514 DOI: 10.7499/j.issn.1008-8830.2003253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To study the occurrence of serious adverse events (SAEs) related to chemotherapy with CCCG-ALL-2015 regimen in children with acute lymphoblastic leukemia (ALL) and the risk factors for death after the SAEs. METHODS A retrospective analysis was performed on the medical data of 734 children with ALL. They were treated with CCCG-ALL-2015 regimen from January 2015 to June 2019. The occurrence of SAEs during the treatment was investigated. The children with SAEs were divided into a death group with 25 children and a survival group with 31 children. A multivariate logistic regression analysis was used to analyze the risk factors for death after the SAEs. RESULTS Among the 734 children with ALL, 56 (7.6%) experienced SAEs (66 cases) after chemotherapy, among which 41 cases occurred in the stage of remission induction therapy. Of all 66 cases of SAEs, 46 (70%) were infection-related SAEs, including 25 cases of septic shock (38%), 20 cases of severe pneumonia (30%), and 1 case of severe chickenpox (2%), and 87% of the children with infection-related SAEs had neutrophil deficiency. The most common infection sites were blood and the lungs. The most common pathogens were Gram-negative bacteria, viruses, fungi, and Gram-positive bacteria. There were 16 cases (24%) of hemorrhage-related SAEs, with 11 cases of gastrointestinal bleeding (17%), 4 cases of pulmonary bleeding (6%), and 1 case of intracranial bleeding (2%). Of all 734 children with ALL, 66 (9.0%) died, among whom 25 died due to SAEs. The treatment-related mortality rate was 3.4%, and infection (72%) and bleeding (24%) were the main causes of death. Severe pneumonia was an independent risk factor for treatment-related death in ALL children (OR=4.087, 95%CI: 1.161-14.384, P=0.028). CONCLUSIONS SAEs often occur in the stage of remission induction therapy, and infection-related SAEs are more common in ALL children accepting chemotherapy with CCCG-ALL-2015 regimen. The development of severe pneumonia suggests an increased risk for death in these children.
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182
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Chang TY, Du CJ, Chang CC, Chen SH, Chen CJ, Chiu CY, Chiu CH. Human coronavirus OC43 infection associated pneumonia in a girl with acute lymphoblastic leukemia: A case report. Medicine (Baltimore) 2020; 99:e21520. [PMID: 32871999 PMCID: PMC7437800 DOI: 10.1097/md.0000000000021520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
RATIONALE Information regarding the clinical features and outcomes of pneumonia due to an infection with human coronavirus (HCoV)-OC43 in children with cancer is rare. This report presents the clinical features in terms of chest CT scan images which may be used to identify cases of HCoV-OC43 infection induced pneumonia in immunocompromised children. PATIENT CONCERNS We report here a girl with acute lymphoblastic leukemia who developed respiratory symptoms during febrile neutropenia. Rapid clinical progression and nodular lesions on her chest X-ray and computed tomography scans were suggestive of a pulmonary fungal infection. DIAGNOSIS A series of tests eventually confirmed the exclusive presence of HCoV-OC43 by the FilmArray Respiratory Panel from a throat swab sample. INTERVENTIONS After the diagnosis was confirmed, the antimicrobial agents initially administered were discontinued. OUTCOMES Although the chest CT scan images looked severe, the clinical course of the infection induced pneumonia was benign. The respiratory status of the patient was completely resolved in 2 weeks. LESSONS This report highlights the importance of early identification of respiratory viruses, via the realization of their clinical characteristics, which helps reduce the duration of administration of antimicrobial agents in this setting.
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Affiliation(s)
| | | | | | | | | | - Chih-Yung Chiu
- Division of Pediatric Pulmonology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Pediatric Febrile Neutropenia: Change in Etiology of Bacteremia, Empiric Choice of Therapy and Clinical Outcomes. J Pediatr Hematol Oncol 2020; 42:e445-e451. [PMID: 32404688 DOI: 10.1097/mph.0000000000001814] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The optimal choice of initial antibiotic therapy for patients with high-risk febrile neutropenia (FN) in children is unclear and varies by the institution on the basis of local antibiograms and epidemiology of specific pathogens. The authors evaluated the appropriateness of antibiotics for the empiric treatment of FN in pediatric patients with cancer in our institution on the basis of changes in the epidemiology of organisms isolated from blood cultures (BCx). METHODS The authors conducted a retrospective medical record review of pediatric patients who received any oncology care (including patients with cancer and patients who had stem cell transplant) at University of Chicago Medicine Comer Children's Hospitals (March 2009 to December 2016) with a diagnosis of FN who had at least 1 BCx obtained. They reviewed pathogens isolated from BCx and determined whether they were pathogens or contaminants using the Infectious Diseases Society of America (IDSA) guidelines and the team's decision to treat. They investigated the microbiologic spectrum and susceptibility patterns of pathogens causing bacteremia in pediatric FN and whether the empiric therapy chosen may have affected clinical outcomes. RESULTS A total of 667 FN episodes were identified in 268 patients. BCx were negative in 497 (74.5%) and were determined to be contaminants in 27 (4%). In 143 episodes (21.5%), the BCx were positive for a pathogenic species. Polymicrobial bacteremia was identified in 25 episodes; a total of 176 pathogens were isolated. The majority of pathogens (95/176, 54%) were Gram-positive (GP), whereas 64 of 162 (36%) were Gram-negative (GN), 5 were fungal, and 4 were mycobacterial. The most common GP pathogens were viridans group streptococci (VGS) (n=34, 19.3%), coagulase-negative staphylococci (n=25, 14%), and methicillin-susceptible Staphylococcus aureus (n=12, 6.8%). Of aerobic GN bacilli, 15 (8.5%) were AmpC producers and 3 (1.7%) carried extended-spectrum beta-lactamases. There was no increase in the prevalence of multidrug-resistant GN isolates during the study period. Patients with VGS and multidrug-resistant GN bacteremia were more likely to be admitted to the pediatric intensive care unit [odds ratio (OR), 3.24; P=0.017; and OR, 2.8; P=0.07, respectively]. There were trends toward a higher prevalence of GP pathogens causing bacteremia and the emergence of VGS with decreased penicillin sensitivity. The prevalence of bacteremia with VGS was higher in acute myelogenous leukemia and neuroblastoma (OR, 2.3; P<0.01) than in patients with other solid tumors. CONCLUSIONS Empiric antibiotic treatment should be tailored to patients' risk for VGS and multidrug-resistant organisms. Individual hospitals should monitor the pathogens causing FN among patients with cancer to guide choice of empiric therapy.
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Haeusler GM, Gaynor L, Teh B, Babl FE, Orme LM, Segal A, Mechinaud F, Bryant PA, Phillips B, Lourenco RDA, Slavin MA, Thursky KA. Home-based care of low-risk febrile neutropenia in children-an implementation study in a tertiary paediatric hospital. Support Care Cancer 2020; 29:1609-1617. [PMID: 32740894 DOI: 10.1007/s00520-020-05654-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 07/24/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Home-based management of low-risk febrile neutropenia (FN) is safe, improves quality of life and reduces healthcare expenditure. A formal low-risk paediatric program has not been implemented in Australia. We aimed to describe the implementation process and evaluate the clinical impact. METHOD This prospective study incorporated three phases: implementation, intervention and evaluation. A low-risk FN implementation toolkit was developed, including a care-pathway, patient information, home-based assessment and educational resources. The program had executive-level endorsement, a multidisciplinary committee and a nurse specialist. Children with cancer and low-risk FN were eligible to be transferred home with a nurse visiting daily after an overnight period of observation for intravenous antibiotics. Low-risk patients were identified using a validated decision rule, and suitability for home-based care was determined using disease, chemotherapy and patient-level criteria. Plan-Do-Study-Act methodology was used to evaluate clinical impact and safety. RESULTS Over 18 months, 292 children with FN were screened: 132 (45%) were low-risk and 63 (22%) were transferred to home-based care. Compared with pre-implementation there was a significant reduction in in-hospital median LOS (4.0 to 1.5 days, p < 0.001) and 291 in-hospital bed days were saved. Eight (13%) patients needed readmission and there were no adverse outcomes. A key barrier was timely screening of all patients and program improvements, including utilising the electronic medical record for patient identification, are planned. CONCLUSION This program significantly reduces in-hospital LOS for children with low-risk FN. Ongoing evaluation will inform sustainability, identify areas for improvement and support national scale-up of the program.
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia. .,University of Melbourne, Parkville, Victoria, Australia. .,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia. .,The Paediatric Integrated Cancer Service, Parkville, Victoria, Australia. .,Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia. .,Murdoch Children's Research Institute, Parkville, Victoria, Australia.
| | - Lynda Gaynor
- The Paediatric Integrated Cancer Service, Parkville, Victoria, Australia.,Hospital In The Home Department, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Benjamin Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Emergency Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Lisa M Orme
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Ahuva Segal
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Francoise Mechinaud
- Unité d'hématologie immunologie pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, Paris, France
| | - Penelope A Bryant
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Hospital In The Home Department, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, New South Wales, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, 3010, Australia.,Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, 3010, 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
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185
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Procalcitonin Clearance, CD64, and HLA-DR as Predictors of Outcome in Febrile Neutropenic Children With Lymphoreticular Malignancies. J Pediatr Hematol Oncol 2020; 42:e416-e422. [PMID: 32590420 DOI: 10.1097/mph.0000000000001870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Febrile neutropenia (FN) is a dreaded complication of cancer chemotherapy. There has been a lot of improvement in supportive care in FN that has drastically reduced the infection-related mortality in these patients. The focus now is on reducing infection-related morbidity, healthcare costs and optimizing the quality of life of the child as well as their family during these episodes. In this study, biomarkers were studied as predictors of outcome so that outcome can be predicted earlier, and treatment modified accordingly. OBJECTIVE To measure procalcitonin levels (at baseline and day 3), procalcitonin clearance, neutrophil CD64 expression levels (at baseline) and monocyte HLA-DR expression levels (at baseline), and their correlation with outcome. SETTING Tertiary care hospital. STUDY TYPE Cross-sectional observational study. POPULATION/PARTICIPANTS Sixty-five episodes of FN in children below 12 years with lymphoreticular malignancies. Children receiving antibacterial and/or antifungal treatment within the last 7 days were excluded from the study. METHODS The subjects recruited into the study had undergone complete clinical and laboratory evaluation as per hospital protocol. Procalcitonin (day 0 and 3), neutrophil CD64 expression, and monocytic HLA-DR expression levels were measured in these patients. RESULTS Sixty-five episodes of FN were studied in children with lymphoreticular malignancy. It was found that procalcitonin and HLA-DR are very good markers of outcome, whereas CD64 although a good marker, was inferior to procalcitonin and HLA-DR in predicting outcome. Procalcitonin clearance was found to be superior to single value of procalcitonin. Furthermore, procalcitonin on day 3 was found to be a better predictor of outcome compared with its baseline value. Also, it was found that procalcitonin and HLA-DR had a significant correlation with baseline C-reactive protein levels. CONCLUSIONS On the basis of the findings of the study we suggest that serial monitoring of procalcitonin levels be used in febrile neutropenic children with cancer. Procalcitonin levels on day 3 alone can be offered in resource poor setting. The role of HLA-DR and CD64 also seems promising and needs to be further explored in larger multicentric studies.
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Davies K, Barth M, Armenian S, Audino AN, Barnette P, Cuglievan B, Ding H, Ford JB, Galardy PJ, Gardner R, Hanna R, Hayashi R, Kovach AE, Machnitz AJ, Maloney KW, Marks L, Page K, Reilly AF, Weinstein JL, Xavier AC, McMillian NR, Freedman-Cass DA. Pediatric Aggressive Mature B-Cell Lymphomas, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 18:1105-1123. [PMID: 32755986 DOI: 10.6004/jnccn.2020.0036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pediatric aggressive mature B-cell lymphomas are the most common types of non-Hodgkin lymphoma in children, and they include Burkitt lymphoma (BL) and diffuse large B-cell lymphoma (DLBCL). These diseases are highly aggressive but curable, the treatment is complex, and patients may have many complicated supportive care issues. The NCCN Guidelines for Pediatric Aggressive Mature B-Cell Lymphomas provide guidance regarding pathology and diagnosis, staging, initial treatment, disease reassessment, surveillance, therapy for relapsed/refractory disease, and supportive care for clinicians who treat sporadic pediatric BL and DLBCL.
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Affiliation(s)
- Kimberly Davies
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center
| | | | | | - Anthony N Audino
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - Hilda Ding
- UCSD Rady Children's Hospital/UC San Diego Moores Cancer Center
| | | | | | - Rebecca Gardner
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Rabi Hanna
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Robert Hayashi
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - Kelly W Maloney
- Children's Hospital of Colorado/University of Colorado Cancer Center
| | | | | | - Anne F Reilly
- Abramson Cancer Center at the University of Pennsylvania
| | | | - Ana C Xavier
- Children's of Alabama/O'Neal Comprehensive Cancer Center at UAB; and
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Wahlund M, Sinha I, Broliden K, Saghafian-Hedengren S, Nilsson A, Berggren A. The Feasibility of Host Transcriptome Profiling as a Diagnostic Tool for Microbial Etiology in Childhood Cancer Patients with Febrile Neutropenia. Int J Mol Sci 2020; 21:ijms21155305. [PMID: 32722616 PMCID: PMC7432212 DOI: 10.3390/ijms21155305] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/13/2020] [Accepted: 07/21/2020] [Indexed: 12/23/2022] Open
Abstract
Infection is a common and serious complication of cancer treatment in children that often presents as febrile neutropenia (FN). Gene-expression profiling techniques can reveal transcriptional signatures that discriminate between viral, bacterial and asymptomatic infections in otherwise healthy children. Here, we examined whether gene-expression profiling was feasible in children with FN who were undergoing cancer treatment. The blood transcriptome of the children (n = 63) was investigated at time of FN diagnosed as viral, bacterial, co-infection or unknown etiology, respectively, and compared to control samples derived from 12 of the patients following the FN episode. RNA sequencing was successful in 43 (68%) of the FN episodes. Only two genes were significantly differentially expressed in the bacterial versus the control group. Significantly up-regulated genes in patients with the other three etiologies versus the control group were enriched with cellular processes related to proliferation and cellular stress response, with no clear enrichment with innate responses to pathogens. Among the significantly down-regulated genes, a few clustered into pathways connected to responses to infection. In the present study of children during cancer treatment, the blood transcriptome was not suitable for determining the etiology of FN because of too few circulating immune cells for reliable gene expression analysis.
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Affiliation(s)
- Martina Wahlund
- Department of Medicine Solna, Infectious Disease Unit, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institutet, 171 76 Stockholm, Sweden; (M.W.); (K.B.)
- Clinical Microbiology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Indranil Sinha
- Childhood Cancer Research Unit, Department of Women’s and Children’s Health, Karolinska Institutet, 171 76 Stockholm, Sweden; (I.S.); (S.S.-H.); (A.N.)
| | - Kristina Broliden
- Department of Medicine Solna, Infectious Disease Unit, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institutet, 171 76 Stockholm, Sweden; (M.W.); (K.B.)
| | - Shanie Saghafian-Hedengren
- Childhood Cancer Research Unit, Department of Women’s and Children’s Health, Karolinska Institutet, 171 76 Stockholm, Sweden; (I.S.); (S.S.-H.); (A.N.)
| | - Anna Nilsson
- Childhood Cancer Research Unit, Department of Women’s and Children’s Health, Karolinska Institutet, 171 76 Stockholm, Sweden; (I.S.); (S.S.-H.); (A.N.)
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Anna Berggren
- Department of Medicine Solna, Infectious Disease Unit, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institutet, 171 76 Stockholm, Sweden; (M.W.); (K.B.)
- Correspondence:
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Cojutti PG, Maximova N, Schillani G, Hope W, Pea F. Population pharmacokinetics of continuous-infusion ceftazidime in febrile neutropenic children undergoing HSCT: implications for target attainment for empirical treatment against Pseudomonas aeruginosa. J Antimicrob Chemother 2020; 74:1648-1655. [PMID: 30838391 DOI: 10.1093/jac/dkz065] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/30/2018] [Accepted: 01/23/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To conduct a population pharmacokinetic analysis of continuous-infusion ceftazidime in a retrospective cohort of paediatric HSCT patients who were empirically treated for febrile neutropenia (FN) and who underwent therapeutic drug monitoring of ceftazidime steady-state plasma concentrations (Css) for optimization of drug exposure. METHODS A non-parametric approach with Pmetrics was used for pharmacokinetic analysis and covariate evaluation. Monte Carlo simulations were performed to calculate the PTA of the pharmacodynamic determinant of efficacy (Css/MIC ≥4) against Pseudomonas aeruginosa with continuous-infusion ceftazidime dosages of 1-6 g daily. The Css safety threshold was arbitrarily placed at 100 mg/L and advisable dosages were used. RESULTS A total of 46 patients with 70 ceftazidime Css values were included. Estimated glomerular filtration rate (eGFR) and body surface area were the covariates associated with drug clearance. At the EUCAST clinical breakpoint of 8 mg/L, simulations showed that continuous-infusion ceftazidime dosages of 4-6 g daily attained optimal PTAs (>90%) across most of 16 different clinical scenarios based on four classes of eGFR (50-145, 145.1-200, 200.1-286 and 286.1-422 mL/min/1.73 m2) and body surface area (0.30-0.64, 0.65-0.88, 0.89-1.34 and 1.35-1.84 m2). In patients with body surface area 0.30-0.64 m2 and eGFR ≤200 mL/min/1.73 m2 the advisable dose of 3 g daily allowed only suboptimal PTAs (<75%). The cumulative fraction of response against MIC distribution of P. aeruginosa was >87%. CONCLUSIONS Continuous-infusion ceftazidime dosages ranging from 3 to 6 g daily according to different classes of eGFR and body surface area may allow optimized empirical treatment of P. aeruginosa infections in paediatric HSCT patients with FN.
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Affiliation(s)
- Pier Giorgio Cojutti
- Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital, ASUIUD, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Natalia Maximova
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Giulia Schillani
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Federico Pea
- Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital, ASUIUD, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
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189
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Bruserud Ø, Aarstad HH, Tvedt THA. Combined C-Reactive Protein and Novel Inflammatory Parameters as a Predictor in Cancer-What Can We Learn from the Hematological Experience? Cancers (Basel) 2020; 12:cancers12071966. [PMID: 32707721 PMCID: PMC7409204 DOI: 10.3390/cancers12071966] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023] Open
Abstract
The acute phase reaction is a systemic response to acute or chronic inflammation. The serum level of C-reactive protein (CRP) is the only acute phase biomarker widely used in routine clinical practice, including its uses for prognostics and therapy monitoring in cancer patients. Although Interleukin 6 (IL6) is a main trigger of the acute phase reactions, a series of acute phase reactants can contribute (e.g., other members in IL6 family or IL1 subfamily, and tumor necrosis factor α). However, the experience from patients receiving intensive chemotherapy for hematological malignancies has shown that, besides CRP, other biomarkers (e.g., cytokines, soluble cytokine receptors, soluble adhesion molecules) also have altered systemic levels as a part of the acute phase reaction in these immunocompromised patients. Furthermore, CRP and white blood cell counts can serve as a dual prognostic predictor in solid tumors and hematological malignancies. Recent studies also suggest that biomarker profiles as well as alternative inflammatory mediators should be further developed to optimize the predictive utility in cancer patients. Finally, the experience from allogeneic stem cell transplantation suggests that selected acute phase reactants together with specific markers of organ damages are useful for predicting or diagnosing graft versus host disease. Acute phase proteins may also be useful to identify patients (at risk of) developing severe immune-mediated toxicity after anticancer immunotherapy. To conclude, future studies of acute phase predictors in human malignancies should not only investigate the conventional inflammatory mediators (e.g., CRP, white blood cell counts) but also combinations of novel inflammatory parameters with specific markers of organ damages.
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Affiliation(s)
- Øystein Bruserud
- Section for Hematology, Institute of Clinical Science, Faculty of Medicine, University of Bergen, 5007 Bergen, Norway;
- Section for Hematology, Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway;
- Correspondence: ; Tel.: +47-5597-2997
| | - Helene Hersvik Aarstad
- Section for Hematology, Institute of Clinical Science, Faculty of Medicine, University of Bergen, 5007 Bergen, Norway;
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Meryk A, Kropshofer G, Hutter J, Fritz J, Salvador C, Lass-Flörl C, Crazzolara R. Benefits of risk-adapted and mould-specific antifungal prophylaxis in childhood leukaemia. Br J Haematol 2020; 191:816-824. [PMID: 32621534 PMCID: PMC7754307 DOI: 10.1111/bjh.16931] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/28/2020] [Accepted: 06/08/2020] [Indexed: 11/29/2022]
Abstract
Fluconazole is one of the most commonly used drugs for antifungal prophylaxis in childhood leukaemia. However, its interaction with vincristine may induce neuropathy and the emergence of antifungal drug resistance contributes to substantial mortality caused by invasive fungal infections (IFIs). In a retrospective single‐centre study, we compared tolerability and outcome of different antifungal prophylaxis strategies in 198 children with acute leukaemia (median age 5·3 years). Until 2010, antifungal prophylaxis with fluconazole was offered to most of the patients and thereafter was replaced by liposomal amphotericin‐B (L‐AMB) and restricted to high‐risk patients only. Vincristine‐induced neurotoxicity was significantly reduced under L‐AMB, as the percentage of patients with severe constipation decreased (15·4% vs. 3·7%, before vs. after 31 December·2010, P = 0·01) and stool frequency increased by up to 38% in polyene‐treated patients (P = 0·005). Before 2011, 10 patients developed confirmed IFIs, most of them were infected with Aspergillus species. After risk adaption in 2011, IFIs were completely prevented (P = 0·007). L‐AMB prophylaxis is beneficial in childhood leukaemia patients, as it offers effective antifungal activity with improved tolerability as compared to fluconazole. The potential impact of our risk‐adapted antifungal treatment should be included in current prophylaxis guidelines for childhood leukaemia.
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Affiliation(s)
- Andreas Meryk
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Gabriele Kropshofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Julia Hutter
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Josef Fritz
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Christina Salvador
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Roman Crazzolara
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
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39·0°C versus 38·5°C ear temperature as fever limit in children with neutropenia undergoing chemotherapy for cancer: a multicentre, cluster-randomised, multiple-crossover, non-inferiority trial. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:495-502. [DOI: 10.1016/s2352-4642(20)30092-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/24/2020] [Accepted: 03/24/2020] [Indexed: 02/01/2023]
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Simon A, Lehrnbecher T, Groll AH, Laws HJ, Ammann RA. Step-down and move forward. Pediatr Blood Cancer 2020; 67:e28342. [PMID: 32383822 DOI: 10.1002/pbc.28342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Arne Simon
- Pediatric Oncology and Hematology, Children's Hospital Medical Center, University Clinics, Homburg, Germany
| | - Thomas Lehrnbecher
- Division for Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Andreas H Groll
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Hans-Jürgen Laws
- Department of Pediatric Oncology, Hematology and Clinical Immunology, University of Duesseldorf, Duesseldorf, Germany
| | - Roland A Ammann
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Assessment of Serum Galactomannan Test Results of Pediatric Patients With Hematologic Malignancies According to Consecutive Positivity and Threshold Level in Terms of Invasive Aspergillosis Diagnosis: Cross-Sectional Research in a Tertiary Care Hospital. J Pediatr Hematol Oncol 2020; 42:e271-e276. [PMID: 31725542 DOI: 10.1097/mph.0000000000001653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to evaluate the diagnostic utility of serum galactomannan (GM) positivity for invasive aspergillosis (IA) in children. Positive GM results between January 2015 and August 2017 were reviewed retrospectively in children with hematologic malignancies. Single and consecutive positive GM results were evaluated according to the different galactomannan index (GMI) (>0.5, >0.7, >1.0 and >1.5) values. There were 104 positive GM results of 70 patients. IA was identified in 29 patients (41.4%) (2 proven and 27 probable). For a single positive GMI of >0.5, >0.7, >1.0, and >1.5, the numbers were 104, 76, 57, and 32 and the positive predictive values (PPVs) were 39.4%, 43.2%, 47.2%, and 50.0%, respectively. The single GM positivity at different thresholds showed no difference between the IA and non-IA group (P>0.05). For 2 consecutive positive GMI values of >0.5, >0.7, >1.0, and >1.5, the numbers were 34, 20, 13, and 4, and the PPVs were 58.8%, 65.0%, 84.6%, and 100.0%, respectively. In the IA group, positivity was higher at all thresholds (P<0.05). According to our findings, consecutive GM positivity has higher PPVs independently from the cutoff value chosen. In pediatric patients with high risk, consecutive sampling should be preferred.
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Management of children with fever and neutropenia: results of a survey in 51 pediatric cancer centers in Germany, Austria, and Switzerland. Infection 2020; 48:607-618. [PMID: 32524514 PMCID: PMC7395019 DOI: 10.1007/s15010-020-01462-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/02/2020] [Indexed: 12/19/2022]
Abstract
Purpose Investigation of the current practice of diagnostics and treatment in pediatric cancer patients with febrile neutropenia. Methods On behalf of the German Society for Pediatric Oncology and Hematology and the German Society for Pediatric Infectious Diseases, an Internet-based survey was conducted in 2016 concerning the management of febrile neutropenia in pediatric oncology centers (POC). This survey accompanied the release of the corresponding German guideline to document current practice before its implementation in clinical practice. Results In total, 51 POCs participated (response rate 73%; 43 from Germany, and 4 each from Austria and Switzerland). Identified targets for antimicrobial stewardship concerned blood culture diagnostics, documentation of the time to antibiotics, the use of empirical combination therapy, drug monitoring of aminoglycosides, the time to escalation in patients with persisting fever, minimal duration of IV treatment, sequential oral treatment in patients with persisting neutropenia, indication for and choice of empirical antifungal treatment, and the local availability of a pediatric infectious diseases consultation service. Conclusion This survey provides useful information for local antibiotic stewardship teams to improve the current practice referring to the corresponding national and international guidelines. Electronic supplementary material The online version of this article (10.1007/s15010-020-01462-z) contains supplementary material, which is available to authorized users.
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Siegmund M, Pagel J, Scholz T, Rupp J, Härtel C, Lauten M. Pro-inflammatory cytokine ratios determine the clinical course of febrile neutropenia in children receiving chemotherapy. Mol Cell Pediatr 2020; 7:5. [PMID: 32519027 PMCID: PMC7283414 DOI: 10.1186/s40348-020-00097-2] [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: 03/03/2020] [Accepted: 05/21/2020] [Indexed: 11/23/2022] Open
Abstract
Background Febrile neutropenia is a common and serious complication during treatment of childhood cancer. Empirical broad-spectrum antibiotics are usually administered until neutrophil cell count recovery. It was the aim of this study to investigate cytokine profiles as potential biomarkers using in-vitro sepsis models to differentiate between distinct clinical courses of febrile neutropenia (FN). Methods We conducted an observational study in FN episodes of pediatric oncology patients. Courses of neutropenia were defined as severe in case of proven blood stream infection or clinical evidence of complicated infection. We collected blood samples at various time points from the onset of FN and stimulated ex vivo with lipopolysaccharide (LPS) and Staphylococcus epidermidis (SE) for 24 h. Twenty-seven cytokine levels were measured in the whole blood culture supernatants by a multiplex immunoassay system. Results Forty-seven FN episodes from 33 children were investigated. IL-8, IL-1β, and MCP-1 expression increased significantly over time. IL-8, MIP-1α, MIP-1β, MCP-1, and TNF-α showed significantly lower concentration in patients with a clinically severe course of the FN. Conclusions Distinct patterns of cytokine profiles seem to be able to determine infectious FN and to predict the severity of its clinical course. If these data can be verified in a multi-centre setting, this may finally lead to an individualized treatment strategy facilitating antibiotic stewardship in these patients.
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Affiliation(s)
- Mira Siegmund
- Department of Pediatrics, Pediatric Hematology and Oncology, University of Lübeck, 23538, Lübeck, Germany
| | - Julia Pagel
- Department of Pediatrics, Pediatric Hematology and Oncology, University of Lübeck, 23538, Lübeck, Germany.,Department of Infectious Diseases and Microbiology, University of Lübeck, Lübeck, Germany.,German Center for Infection Research (DZIF), partner site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany
| | - Tasja Scholz
- Department of Pediatrics, Pediatric Hematology and Oncology, University of Lübeck, 23538, Lübeck, Germany
| | - Jan Rupp
- Department of Infectious Diseases and Microbiology, University of Lübeck, Lübeck, Germany.,German Center for Infection Research (DZIF), partner site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany
| | - Christoph Härtel
- Department of Pediatrics, Pediatric Hematology and Oncology, University of Lübeck, 23538, Lübeck, Germany
| | - Melchior Lauten
- Department of Pediatrics, Pediatric Hematology and Oncology, University of Lübeck, 23538, Lübeck, Germany.
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196
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Haeusler GM, Phillips R, Slavin MA, Babl FE, De Abreu Lourenco R, Mechinaud F, Thursky KA. Re-evaluating and recalibrating predictors of bacterial infection in children with cancer and febrile neutropenia. EClinicalMedicine 2020; 23:100394. [PMID: 32637894 PMCID: PMC7329706 DOI: 10.1016/j.eclinm.2020.100394] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Numerous paediatric febrile neutropenia (FN) clinical decision rules (CDRs) have been derived. Validation studies show reduced performance in external settings. We evaluated the association between variables common across published FN CDRs and bacterial infection and recalibrated existing CDRs using these data. METHODS Prospective data from the Australian-PICNICC study which enrolled 858 FN episodes in children with cancer were used. Variables shown to be significant predictors of infection or adverse outcome in >1 CDR were analysed using multivariable logistic regression. Recalibration included re-evaluation of beta-coefficients (logistic model) or recursive-partition analysis (tree-based models). FINDINGS Twenty-five unique variables were identified across 17 FN CDRs. Fourteen were included in >1 CDR and 10 were analysed in our dataset. On univariate analysis, location, temperature, hypotension, rigors, severely unwell and decreasing platelets, white cell count, neutrophil count and monocyte count were significantly associated with bacterial infection. On multivariable analysis, decreasing platelets, increasing temperature and the appearance of being clinically unwell remained significantly associated. Five rules were recalibrated. Across all rules, recalibration increased the AUC-ROC and low-risk yield as compared to non-recalibrated data. For the SPOG-adverse event CDR, recalibration also increased sensitivity and specificity and external validation showed reproducibility. INTERPRETATION Degree of marrow suppression (low platelets), features of inflammation (temperature) and clinical judgement (severely unwell) have been consistently shown to predict infection in children with FN. Recalibration of existing CDRs is a novel way to improve diagnostic performance of CDRs and maintain relevance over time. FUNDING National Health and Medical Research Council Grant (APP1104527).
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- The Paediatric Integrated Cancer Service, Parkville, Victoria State Government, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Australia
- Murdoch Children's Research Institute, Parkville, Australia
- Corresponding author: Dr Gabrielle M. Haeusler, Department of Infectious Diseases, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Australia, 3000, P: +61 3 9656 5853 F: +61 3 9656 1185.
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, United Kingdom
| | - Monica A. Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute, Parkville, Australia
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Broadway, Australia
| | - Francoise Mechinaud
- Unité d'hématologie immunologie pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, France
| | - Karin A. Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
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197
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Mueller EL, Jacob SA, Cochrane AR, Carroll AE, Bennett WE. Variation in hospital admission from the emergency department for children with cancer: A Pediatric Health Information System study. Pediatr Blood Cancer 2020; 67:e28140. [PMID: 32275120 PMCID: PMC8955607 DOI: 10.1002/pbc.28140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/21/2019] [Accepted: 11/25/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Children with cancer experience a wide range of conditions that require urgent evaluation in the emergency department (ED), yet variation in admission rates is poorly documented. PROCEDURE We performed a retrospective cohort study using the Pediatric Health Information System of ED encounters by children with cancer between July 2012 and June 2015. We compared demographics for admitted versus discharged using univariate statistics, and calculated admission rates by hospital, diagnosis, day of the week, and weekend versus weekday. We assessed the degree of interhospital admission rates using the index of dispersion (ID). RESULTS Children with cancer had 60 054 ED encounters at 37 hospitals. Overall, 62.5% were admitted (range 43.2%-92.1%, ID 2.6) indicating overdispersed admission rates with high variability. Children with cancer that visited the ED for a primary diagnosis of fever experienced the largest amount of variability in admission with rates ranging from 10.4% to 74.1% (ID 8.1). Less variability existed among hospital admission rates for both neutropenia (range 60%-100%, ID 1.0) and febrile neutropenia (FN) (range 66.7%-100%, ID 0.83). Admission rates by day of the week did not demonstrate significant variability for any of the scenarios examined (overall P = 0.91). There were no differences by weekend versus weekday either (overall P = 0.52). CONCLUSION The percentage of children with cancer admitted through the ED varies widely by institution and diagnosis. Standardization of best practices for children with cancer admitted through the ED should be an area of continued improvement.
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Affiliation(s)
- Emily L. Mueller
- Division of Pediatric Hematology Oncology, Department of Pediatrics, Indiana University, Indianapolis, Indiana,Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University, Indianapolis, Indiana
| | - Seethal A. Jacob
- Division of Pediatric Hematology Oncology, Department of Pediatrics, Indiana University, Indianapolis, Indiana,Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University, Indianapolis, Indiana
| | - Anneli R. Cochrane
- Division of Pediatric Hematology Oncology, Department of Pediatrics, Indiana University, Indianapolis, Indiana,Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University, Indianapolis, Indiana
| | - Aaron E. Carroll
- Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University, Indianapolis, Indiana,Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - William E. Bennett
- Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University, Indianapolis, Indiana,Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
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198
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Abstract
BACKGROUND Several evidence-based guidelines for the management of children with febrile neutropenia (FN) have been published, with special focus in bacterial and fungal infections. However, the role of acute respiratory infections caused by respiratory viruses (RV) has not been clearly established. The aim of this study was to evaluate the epidemiology, clinical presentation and outcome of acute respiratory infections in children with FN. METHODS Patients, <18 years of age admitted to the Pediatric Oncology-Hematology Unit after developing FN between November 2010 and December 2013, were prospectively included in the study. Children were evaluated by clinical examination and laboratory tests. Nasopharyngeal sample was obtained for detection of RV. RESULTS There was a total of 112 episodes of FN in 73 children admitted to the hospital during a 32-month period. According to disease severity, 33% of the episodes were considered moderate or severe. Rhinovirus was the most frequently detected RV (66.6%; 24/36), followed by parainfluenza. On regard to clinical outcome, RV-infected children developed fewer episodes of moderate or severe FN compared with non-RV infected children (16.7% vs. 33.3%; P = 0.08). CONCLUSIONS A great proportion of children with FN admitted to a tertiary hospital had a RV isolation. The rate of this RV isolation was significantly higher when a rapid molecular test was used compared with conventional microbiologic methods. Rhinovirus was the most frequently isolated, although its role as an active agent of acute infection was not clear. Children with FN and a RV isolate had a lower rate of severe disease.
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199
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Avilés-Robles MJ, Reyes-López A, Otero-Mendoza FJ, Valencia-Garin AU, Peñaloza-González JG, Rosales-Uribe RE, Muñoz-Hernández O, Garduño-Espinosa J, Juárez-Villegas L, Zapata-Tarrés M. Safety and efficacy of step-down to oral outpatient treatment versus inpatient antimicrobial treatment in pediatric cancer patients with febrile neutropenia: A noninferiority multicenter randomized clinical trial. Pediatr Blood Cancer 2020; 67:e28251. [PMID: 32196898 DOI: 10.1002/pbc.28251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/04/2020] [Accepted: 02/24/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND It has been suggested that low-risk febrile neutropenia (FN) episodes can be treated in a step-down manner in the outpatient setting. This recommendation has been limited to implementation in middle-income countries due to concerns about infrastructure and lack of trained personnel. We aimed to determine whether early step-down to oral antimicrobial outpatient treatment is not inferior in safety and efficacy to inpatient intravenous treatment in children with low-risk FN. PROCEDURE A noninferiority randomized controlled clinical trial was conducted in three hospitals in Mexico City. Low-risk FN was identified in children younger than 18 years. After 48 to 72 hours of intravenous treatment, children were randomly allocated to receive outpatient oral treatment (experimental arm, cefixime) or to continue inpatient treatment (standard of care, cefepime). Daily monitoring was performed until neutropenia resolution. The presence of any unfavorable clinical outcome was the endpoint of interest. We performed a noninferiority test for comparison of proportions. RESULTS We identified 1237 FN episodes; 117 cases were randomized: 60 to the outpatient group and 57 for continued inpatient treatment. Of the FN episodes, 100% in the outpatient group and 93% in the inpatient group had a favorable outcome (P < 0.001). The mean duration of antibiotics was 4.1 days (SD 2.5; 95% CI, 3.4-4.8 days) in the outpatient group and 4.4 days (SD 2.5; 95% CI, 3.7-5.0 days) in the inpatient group (P = 0.70). CONCLUSIONS In our population, step-down oral outpatient treatment of low-risk FN was as safe and effective as inpatient intravenous treatment. Clinical Trials Identifier: NCT04000711.
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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
| | | | | | | | - Rómulo E Rosales-Uribe
- Subdivision of Integral Attention to the Patient, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | | | - Juan Garduño-Espinosa
- Research Department, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Luis Juárez-Villegas
- Oncology Department, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
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200
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Delgado-Araneda M, Valenzuela R, de la Maza V, Rabello M, Álvarez AM, Contardo V, Zubieta M, Gutierrez V, Claverie X, Torres JP, Salgado C, Tordecilla J, Varas M, Avilés CL, Venegas M, Villarroel M, Santolaya ME. Usefulness of serum galactomannan in initiating and modifying antifungal therapy in children with cancer and persistent high-risk febrile neutropenia. Mycoses 2020; 63:802-811. [PMID: 32347600 DOI: 10.1111/myc.13097] [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: 01/31/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Invasive fungal disease is a major cause of morbidity and mortality in children with cancer and high-risk febrile neutropenia (HRFN). Repeated serum galactomannan (sGM) measurements have been described as an effective tool to guide therapy in adults under suspicion of invasive aspergillosis. However, the utility of this approach has not been reported in paediatric population. OBJECTIVES To evaluate the usefulness of sGM measurements in initiating and modifying antifungal therapy (AFT) in children with cancer and persistent HRFN. PATIENTS/METHODS Nested case-control study in children with cancer and persistent HRFN episodes, between July 2013 and January 2019. Patients were classified as cases and controls depending on if they received AFT or not, respectively. Through odds ratio analysis, we assessed the role of sGM positivity in the AFT initiation decision. Then, we analysed the group of patients that initiated AFT, and compared those who had AFT modifications and those who did not, analysing different sGM kinetics thresholds. RESULTS A total of 191 episodes from children with persistent HRFN were enrolled, of which 107 received AFT and 84 did not. The median age was 7 years (IQR 4-12), 52% were male and 89% had a haematologic malignancy as underlying disease. Positive sGM was not associated with AFT initiation (OR 0.99, 95% CI 0.43-2.33, P = .99). A difference threshold in sGM Δ ≥ 0.3 sGM was significantly associated with AFT modification (OR 5.07, 95% CI 1.02- 25.70, P = .04). CONCLUSIONS Our results suggest the utility of serial sGM sampling during AFT in children with persistent HRFN.
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Affiliation(s)
- Matías Delgado-Araneda
- Department of Pediatrics, Residency and Medical Sciences Doctorate Program, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Romina Valenzuela
- Department of Pediatrics, Faculty of Medicine, Hospital Dr. Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile
| | - Verónica de la Maza
- Department of Pediatrics, Faculty of Medicine, Hospital Dr. Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile
| | - Marcela Rabello
- Department of Pediatrics, Faculty of Medicine, Hospital Dr. Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile
| | - Ana M Álvarez
- Department of Pediatrics, Faculty of Medicine, Hospital San Juan de Dios, Universidad de Chile, Santiago, Chile.,Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Verónica Contardo
- Department of Pediatrics, Faculty of Medicine, Hospital Roberto del Río, Universidad de Chile, Santiago, Chile.,Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Marcela Zubieta
- Department of Pediatrics, Hospital Exequiel González Cortés, Faculty of Medicine, Universidad de Chile, Santiago, Chile.,Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Valentina Gutierrez
- Department of Pediatrics, Hospital Dr. Sótero del Río, Santiago, Chile.,Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Ximena Claverie
- Department of Pediatrics, Hospital Dr. Sótero del Río, Santiago, Chile.,Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Juan P Torres
- Department of Pediatrics, Faculty of Medicine, Hospital Dr. Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile
| | - Carmen Salgado
- Department of Pediatrics, Hospital Exequiel González Cortés, Faculty of Medicine, Universidad de Chile, Santiago, Chile.,Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Juan Tordecilla
- Department of Pediatrics, Faculty of Medicine, Hospital Roberto del Río, Universidad de Chile, Santiago, Chile.,Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Mónica Varas
- Department of Pediatrics, Faculty of Medicine, Hospital San Juan de Dios, Universidad de Chile, Santiago, Chile.,Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Carmen L Avilés
- Department of Pediatrics, Faculty of Medicine, Hospital San Borja Arriarán, Universidad de Chile, Santiago, Chile.,Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Marcela Venegas
- Department of Pediatrics, Faculty of Medicine, Hospital San Borja Arriarán, Universidad de Chile, Santiago, Chile.,Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Milena Villarroel
- Department of Pediatrics, Faculty of Medicine, Hospital Dr. Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile.,Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - María E Santolaya
- Department of Pediatrics, Faculty of Medicine, Hospital Dr. Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile.,Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
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