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Pulcini CD, Lentz S, Saladino RA, Bounds R, Herrington R, Michaels MG, Maurer SH. Emergency management of fever and neutropenia in children with cancer: A review. Am J Emerg Med 2021; 50:693-698. [PMID: 34879488 DOI: 10.1016/j.ajem.2021.09.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Care of pediatric cancer patients is increasingly being provided by physicians in community settings, including general emergency departments. Guidelines based on current evidence have standardized the care of children undergoing chemotherapy or hematopoietic stem cell transplantation (HSCT) presenting with fever and neutropenia (FN). OBJECTIVE This narrative review evaluates the management of pediatric patients with cancer and neutropenic fever and provides comparison with the care of the adult with neutropenic fever in the emergency department. DISCUSSION When children with cancer and FN first present for care, stratification of risk is based on a thorough history and physical examination, baseline laboratory and radiologic studies and the clinical condition of the patient, much like that for the adult patient. Prompt evaluation and initiation of intravenous broad-spectrum antibiotics after cultures are drawn but before other studies are resulted is critically important and may represent a practice difference for some emergency physicians when compared with standardized adult care. Unlike adults, all high-risk and most low-risk children with FN undergoing chemotherapy require admission for parenteral antibiotics and monitoring. Oral antibiotic therapy with close, structured outpatient monitoring may be considered only for certain low-risk patients at pediatric centers equipped to pursue this treatment strategy. CONCLUSIONS Although there are many similarities between the emergency approach to FN in children and adults with cancer, there are differences that every emergency physician should know. This review provides strategies to optimize the care of FN in children with cancer in all emergency practice settings.
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Affiliation(s)
- Christian D Pulcini
- Division of Emergency Medicine, Department of Surgery and Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Skyler Lentz
- Division of Emergency Medicine and Critical Care, Department of Surgery and Medicine, University of Vermont Larner College of Medicine, Burlington, VT, United States of America
| | - Richard A Saladino
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Richard Bounds
- Division of Emergency Medicine, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Ramsey Herrington
- Division of Emergency Medicine, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Marian G Michaels
- Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Scott H Maurer
- Division of Hematology/Oncology, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
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Continuous Intravenous Administration of Granulocyte-Colony-Stimulating Factors-A Breakthrough in the Treatment of Cancer Patients with Febrile Neutropenia. ACTA ACUST UNITED AC 2021; 57:medicina57070675. [PMID: 34208815 PMCID: PMC8305666 DOI: 10.3390/medicina57070675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/17/2021] [Accepted: 06/21/2021] [Indexed: 11/16/2022]
Abstract
Background: Febrile neutropenia (FN) remains one of the most challenging problems in medical oncology and is a very severe side effect of chemotherapy. Its late consequences, when it is recurrent or of a severe grade, are dose reduction and therapy delays. Current guidelines allow the administration of granulocyte-colony-stimulating factors (G-CSF) for profound FN (except for the case when a pegylated form of G-CSF is administrated with prophylactic intention) in addition to antibiotics and supportive care. Methods: This is a prospective study that included 96 patients with confirmed malignancy, treated with chemotherapy, who developed FN during their oncological therapy, and were hospitalized. They received standard treatment plus a dose of G-CSF of 16 µg/Kg/day IV continuous infusion. Results: The gender distribution was almost symmetrical: Male patients made up 48.96% and 51.04% were female patients, with no significance on recovery from FN (p = 1.00). The patients who received prophylactic G-CSF made up 20.21%, but this was not a predictive or prognostic factor for the recovery time from aplasia (p = 0.34). The median chemotherapy line where patients with FN were included was two and the number of previous chemotherapy cycles before FN was three. The median serological number of neutrophils (PMN) was 450/mm3 and leucocytes (WBC) 1875/mm3 at the time of FN. Ten patients possess PMN less than 100/mm3. The median time to recovery was 25.5 h for 96 included patients, with one failure in which the patient possessed grade 5 FN. Predictive factors for shorter recovery time were lower levels of C reactive protein (p < 0.001) and procalcitonin (p = 0.002) upon hospital admission and higher WBC (p = 0.006) and PMN (p < 0.001) at the time of the provoking cycle of chemotherapy for FN. The best chance for a shorter duration of FN was a short history of chemotherapy regarding the number of cycles) (p < 0.0001). Conclusions: Continuous IV administration of G-CSF could be an alternative salvage treatment for patients with profound febrile neutropenia, with a very fast recovery time for neutrophiles.
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Neuroprotection through G-CSF: recent advances and future viewpoints. Pharmacol Rep 2021; 73:372-385. [PMID: 33389706 DOI: 10.1007/s43440-020-00201-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 11/18/2020] [Accepted: 11/21/2020] [Indexed: 12/14/2022]
Abstract
Granulocyte-colony stimulating factor (G-CSF), a member of the cytokine family of hematopoietic growth factors, is 19.6 kDa glycoprotein which is responsible for the proliferation, maturation, differentiation, and survival of neutrophilic granulocyte lineage. Apart from its proven clinical application to treat chemotherapy-associated neutropenia, recent pre-clinical studies have highlighted the neuroprotective roles of G-CSF i.e., mobilization of haemopoietic stem cells, anti-apoptotic, neuronal differentiation, angiogenesis and anti-inflammatory in animal models of neurological disorders. G-CSF is expressed by numerous cell types including neuronal, immune and endothelial cells. G-CSF is released in autocrine manner and binds to its receptor G-CSF-R which further activates numerous signaling transduction pathways including PI3K/AKT, JAK/STAT and MAP kinase, and thereby promote neuronal survival, proliferation, differentiation, mobilization of hematopoietic stem and progenitor cells. The expression of G-CSF receptors (G-CSF-R) in the different brain regions and their upregulation in response to neuronal insult indicates the autocrine protective signaling mechanism of G-CSF by inhibition of apoptosis, inflammation, and stimulation of neurogenesis. These observed neuroprotective effects of G-CSF makes it an attractive target to mitigate neurodegeneration associated with neurological disorders. The objective of the review is to highlight and summarize recent updates on G-CSF as a therapeutically versatile neuroprotective agent along with mechanisms of action as well as possible clinical applications in neurodegenerative disorders including AD, PD and HD.
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Pérez-Heras Í, Raynero-Mellado RC, Díaz-Merchán R, Domínguez-Pinilla N. Post chemotherapy febrile neutropenia. Length of stay and experience in our population. An Pediatr (Barc) 2020. [DOI: 10.1016/j.anpede.2019.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Neutropenia febril posquimioterapia. Estancia hospitalaria y experiencia en nuestro medio. An Pediatr (Barc) 2020; 92:141-146. [DOI: 10.1016/j.anpedi.2019.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/17/2019] [Accepted: 05/21/2019] [Indexed: 11/19/2022] Open
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Busca A, Cesaro S, Teofili L, Delia M, Cattaneo C, Criscuolo M, Marchesi F, Fracchiolla NS, Valentini CG, Farina F, Di Blasi R, Prezioso L, Spolzino A, Candoni A, del Principe MI, Verga L, Nosari A, Aversa F, Pagano L. SEIFEM 2017: from real life to an agreement on the use of granulocyte transfusions and colony-stimulating factors for prophylaxis and treatment of infectious complications in patients with hematologic malignant disorders. Expert Rev Hematol 2018; 11:155-168. [DOI: 10.1080/17474086.2018.1420472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Alessandro Busca
- SSD Trapianto Cellule Staminali, A.O.U. Citta’ della Salute, Torino, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata Verona, Italy
| | - Luciana Teofili
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mario Delia
- Dipartimento dell’Emergenza e dei Trapianti Di Organo, U.O Ematologia con Trapianto - Azienda Ospedaliero-Universitaria - Policlinico di Bari, Italy
| | | | - Marianna Criscuolo
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Marchesi
- Hematology and Stem Cell Transplant Unit Regina Elena National Cancer Institute, Rome, Italy
| | | | - Caterina Giovanna Valentini
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Farina
- Unità di ematologia e trapianti di midollo osseo, IRCCS San Raffaele, Milano, Italy
| | - Roberta Di Blasi
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Anna Candoni
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari, Azienda Sanitaria Universitaria Integrata di Udine, Italy
| | | | - Luisa Verga
- Ematologia adulti e CTA ASST Monza, Universita’ Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | - Annamaria Nosari
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Milano.Italy
| | | | - Livio Pagano
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
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Robinson PD, Lehrnbecher T, Phillips R, Dupuis LL, Sung L. Strategies for Empiric Management of Pediatric Fever and Neutropenia in Patients With Cancer and Hematopoietic Stem-Cell Transplantation Recipients: A Systematic Review of Randomized Trials. J Clin Oncol 2016; 34:2054-60. [DOI: 10.1200/jco.2015.65.8591] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Purpose To describe treatment failure and mortality rates with different antibiotic regimens and different management strategies for empirical treatment of fever and neutropenia (FN) in pediatric patients with cancer and hematopoietic stem-cell transplantation (HSCT) recipients. Methods We conducted a systematic review and performed searches of MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials. Studies were included if pediatric patients had cancer or were HSCT recipients and the intervention was related to the management of FN. Strategies synthesized were monotherapy versus aminoglycoside-containing combination therapy; antipseudomonal penicillin monotherapy versus fourth-generation cephalosporin monotherapy; inpatient versus outpatient management; oral versus intravenous antibiotics; and addition of colony-stimulating factors. Results Of 11,469 citations screened, 68 studies randomly assigning 7,265 episodes were included. When compared with monotherapy, aminoglycoside-containing combination therapy did not decrease treatment failures (risk ratio, 1.13; 95% CI, 0.92 to 1.38; P = 0.23), and no difference in mortality was observed. Antipseudomonal penicillin and fourth-generation cephalosporin monotherapy were associated with similar failure and mortality rates. Outpatient management and oral antibiotics were safe in low-risk FN with no infection-related mortality observed in any patient and no significant differences in outcomes compared with inpatient management and intravenous therapy. Therapeutic colony-stimulating factors were associated with a 1.42-day reduction in hospitalization (95% CI, 0.62 to 2.22 days; P < .001). Conclusion There were a moderate number of pediatric randomized trials of FN management. Monotherapy for high-risk FN and outpatient and oral management for low-risk FN are effective strategies. These findings will provide the basis for guideline recommendations in pediatric FN.
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Affiliation(s)
- Paula D. Robinson
- Paula D. Robinson, Pediatric Oncology Group of Ontario; L. Lee Dupuis and Lillian Sung, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; and Robert Phillips, Leeds General Infirmary, Leeds Teaching Hospitals, National Health Service Trust, Leeds, and Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Thomas Lehrnbecher
- Paula D. Robinson, Pediatric Oncology Group of Ontario; L. Lee Dupuis and Lillian Sung, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; and Robert Phillips, Leeds General Infirmary, Leeds Teaching Hospitals, National Health Service Trust, Leeds, and Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Robert Phillips
- Paula D. Robinson, Pediatric Oncology Group of Ontario; L. Lee Dupuis and Lillian Sung, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; and Robert Phillips, Leeds General Infirmary, Leeds Teaching Hospitals, National Health Service Trust, Leeds, and Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - L. Lee Dupuis
- Paula D. Robinson, Pediatric Oncology Group of Ontario; L. Lee Dupuis and Lillian Sung, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; and Robert Phillips, Leeds General Infirmary, Leeds Teaching Hospitals, National Health Service Trust, Leeds, and Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Lillian Sung
- Paula D. Robinson, Pediatric Oncology Group of Ontario; L. Lee Dupuis and Lillian Sung, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; and Robert Phillips, Leeds General Infirmary, Leeds Teaching Hospitals, National Health Service Trust, Leeds, and Centre for Reviews and Dissemination, University of York, York, United Kingdom
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Abstract
Fever in the pediatric population is a common chief complaint presenting to the emergency department and may be one of the first indications of a life-threatening infection, especially in patients with neutropenia. Given that pediatric patients with febrile neutropenia frequently present to emergency departments for emergent care, it is critical for emergency medicine physicians and pediatricians and family physicians working in the emergency department to know the key aspects of the clinical approach to these patients. This review of the clinical evaluation and treatment of the pediatric patient presenting with fever and confirmed or suspected neutropenia will provide health care providers with the necessary tools to effectively care for this patient population.
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Agarwal S, Lakoma A, Chen Z, Hicks J, Metelitsa LS, Kim ES, Shohet JM. G-CSF Promotes Neuroblastoma Tumorigenicity and Metastasis via STAT3-Dependent Cancer Stem Cell Activation. Cancer Res 2015; 75:2566-79. [PMID: 25908586 DOI: 10.1158/0008-5472.can-14-2946] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 04/11/2015] [Indexed: 12/16/2022]
Abstract
Increasing evidence suggests that inflammatory cytokines play a critical role in tumor initiation and progression. A cancer stem cell (CSC)-like subpopulation in neuroblastoma is known to be marked by expression of the G-CSF receptor (G-CSFR). Here, we report on the mechanistic contributions of the G-CSFR in neuroblastoma CSCs. Specifically, we demonstrate that the receptor ligand G-CSF selectively activates STAT3 within neuroblastoma CSC subpopulations, promoting their expansion in vitro and in vivo. Exogenous G-CSF enhances tumor growth and metastasis in human xenograft and murine neuroblastoma tumor models. In response to G-CSF, STAT3 acts in a feed-forward loop to transcriptionally activate the G-CSFR and sustain neuroblastoma CSCs. Blockade of this G-CSF-STAT3 signaling loop with either anti-G-CSF antibody or STAT3 inhibitor depleted the CSC subpopulation within tumors, driving correlated tumor growth inhibition, decreased metastasis, and increased chemosensitivity. Taken together, our results define G-CSF as a CSC-activating factor in neuroblastoma, suggest a comprehensive reevaluation of the clinical use of G-CSF in these patients to support white blood cell counts, and suggest that direct targeting of the G-CSF-STAT3 signaling represents a novel therapeutic approach for neuroblastoma.
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Affiliation(s)
- Saurabh Agarwal
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Cancer Center, Houston, Texas. Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Anna Lakoma
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Zaowen Chen
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Cancer Center, Houston, Texas. Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - John Hicks
- Department of Pathology, Section of Pediatric Pathology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Leonid S Metelitsa
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Cancer Center, Houston, Texas. Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Eugene S Kim
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas. Division of Pediatric Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Los Angeles, California
| | - Jason M Shohet
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Cancer Center, Houston, Texas. Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas.
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Ju HY, Hong CR, Shin HY. Advancements in the treatment of pediatric acute leukemia and brain tumor - continuous efforts for 100% cure. KOREAN JOURNAL OF PEDIATRICS 2014; 57:434-9. [PMID: 25379043 PMCID: PMC4219945 DOI: 10.3345/kjp.2014.57.10.434] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/14/2014] [Indexed: 02/08/2023]
Abstract
Treatment outcomes of pediatric cancers have improved greatly with the development of improved treatment protocols, new drugs, and better supportive measures, resulting in overall survival rates greater than 70%. Survival rates are highest in acute lymphoblastic leukemia, reaching more than 90%, owing to risk-based treatment through multicenter clinical trials and protocols developed to prevent central nervous system relapse and testicular relapse in boys. New drugs including clofarabine and nelarabine are currently being evaluated in clinical trials, and other targeted agents are continuously being developed. Chimeric antigen receptor-modified T cells are now attracting interest for the treatment of recurrent or refractory disease. Stem cell transplantation is still the most effective treatment for pediatric acute myeloid leukemia (AML). However, in order to reduce treatment-related death after stem cell transplantation, there is need for improved treatments. New drugs and targeted agents are also needed for improved outcome of AML. Surgery and radiation therapy have been the mainstay for brain tumor treatment. However, chemotherapy is becoming more important for patients who are not eligible for radiotherapy owing to age. Stem cell transplant as a means of high dose chemotherapy and stem cell rescue is a new treatment modality and is often repeated for improved survival. Drugs such as temozolomide are new chemotherapeutic options. In order to achieve 100% cure in children with pediatric cancer, every possible treatment modality and effort should be considered.
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Affiliation(s)
- Hee Young Ju
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Che Ry Hong
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Young Shin
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Sung L, Zaoutis T, Ullrich NJ, Johnston D, Dupuis L, Ladas E. Children's Oncology Group's 2013 blueprint for research: cancer control and supportive care. Pediatr Blood Cancer 2013; 60:1027-30. [PMID: 23255159 PMCID: PMC4447629 DOI: 10.1002/pbc.24426] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 11/09/2012] [Indexed: 11/07/2022]
Abstract
In cancer control research, the objective is to reduce overall morbidity and mortality by decreasing acute and delayed treatment-related toxicities in all children with cancer. To date, the Children's Oncology Group (COG) has focused on infection, neurocognition, quality of life (QoL), and nutrition/antiemetics. COG is conducting randomized controlled trials (RCTs) to determine prophylaxis strategies that will reduce infections in high-risk populations. Two RCTs are determining if modafinil or computerized cognitive training improve cognitive functioning in pediatric brain tumor patients. QoL is being assessed in acute leukemia patients. Improved supportive care outcomes will only occur when the most effective interventions are established.
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Affiliation(s)
- Lillian Sung
- Department of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Theo Zaoutis
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nicole J. Ullrich
- Department of Neurology, Boston Children’s Hospital and Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Donna Johnston
- Department of Hematology/Oncology, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Lee Dupuis
- Department of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elena Ladas
- Department of Pediatric Oncology, Columbia University Medical Center, New York, New York
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Abstract
Febrile neutropenia is a common emergency encountered in children receiving chemotherapy for a malignancy. Left untreated, it can lead to serious morbidity and mortality. Febrile neutropenia is suspected in any patient on chemotherapy who presents with fever. Prompt evaluation and management by the primary contact pediatrician is essential for a successful outcome. A detailed history and physical examination is warranted to identify source of infection, although two thirds of them may not have localizing symptoms or signs. Risk stratification is valuable in categorizing the severity and guiding therapy. Initial stabilization, prompt initiation of appropriate antibiotics and adequate supportive care are the cornerstone of treatment. Knowledge of the locally prevailing bacteriological profile and antimicrobial susceptibility data is crucial for each hospital/unit to frame and periodically modify guidelines for the choice of antimicrobials. Delay in initiating antimicrobials significantly worsens the outcome. Education of the family as well as the members of the treating unit is important in this regard. Pro-active steps must be taken to reduce incidence of hospital acquired sepsis. Diagnosis and management in relevance to the emergency room is reviewed and institutional practice is shared.
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Affiliation(s)
- Sapna Oberoi
- Hematology-Oncology unit, Department of Pediatrics, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
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13
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Pérez Velasco R. Review of granulocyte colony-stimulating factors in the treatment of established febrile neutropenia. J Oncol Pharm Pract 2010; 17:225-32. [DOI: 10.1177/1078155210374129] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To assess the value of granulocyte colony-stimulating factors (G-CSF) in promoting recovery from established episodes of febrile neutropenia (FN) after chemotherapy in cancer patients. Method: The literature was searched using the MEDLINE, EMBASE, BIOSIS, and IPA databases. Reference lists from the retrieved papers and hand searches of relevant journals complemented the search. Eleven randomized controlled trials were selected for review. Result: G-CSF use in established FN appears to be limited to a small reduction in neutropenia duration, length of hospitalization, and duration of antibiotic use. Overall, there are no significant reductions in time to neutrophil recovery and fever resolution. The cost analyses performed do not show significant cost savings. Conclusion: Granulocyte colony-stimulating factors (G-CSF) are biological agents typically used for prevention of febrile neutropenia (FN) or as adjunctive treatment with antibiotics of established FN. Most clinical guidelines discourage the general use of G-CSF for adjunctive treatment of ongoing neutropenic fever; however, its use in special situations, such as high-risk for infectious complications or adverse prognostic factors, is advised. G-CSF should be reserved for high-risk cancer patients, in accordance with the results of this review. This recommendation needs to be taken with caution in view of the disparities and methodological flaws found among trials. It is necessary to design further trials appropriately, well-powered and focused on high-risk patients. Moreover, it is necessary to perform an appropriate economic evaluation for this setting.
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Affiliation(s)
- Román Pérez Velasco
- Health Intervention and Technology Assessment Program (HITAP), 6th Floor, 6th Building Department of Health, Ministry of Public Health Tiwanon Rd., Muang, Nonthaburi 11000, Thailand,
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Martinez-Albarran M, Perez-Molina JDJ, Gallegos-Castorena S, Sanchez-Zubieta F, Del Toro-Arreola S, Troyo-Sanroman R, Gonzalez-Ramella O. Procalcitonin and C-reactive protein serum levels as markers of infection in a pediatric population with febrile neutropenia and cancer. Pediatr Hematol Oncol 2009; 26:414-25. [PMID: 19657991 DOI: 10.3109/08880010903044797] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Procalcitonin and C-reactive-protein are inflammatory markers for sepsis. The authors evaluated their sensitivity and specificity in pediatric patients with cancer and febrile neutropenia. PROCEDURE Serum procalcitonin and C-reactive-protein were evaluated. Patients (n = 54) were divided into 2 groups, with severe infection (n = 18) or without documented infection (n = 36). RESULTS Procalcitonin and C-reactive protein were significantly higher in the high-risk group. Procalcitonin displayed 72.2% sensitivity and 80.5% specificity. C-reactive-protein had a sensitivity of 77.7% and specificity of 77.2%. CONCLUSIONS Procalcitonin is an accurate predictor of bacterial infection in neutropenic children, while C-reactive-protein may be a better screening test in emergency settings.
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Affiliation(s)
- Manuel Martinez-Albarran
- Departamento de Hematologia y Oncologia Pediatrica, Hospital Civil de Guadalajara Juan I. Menchaca, Guadalajara, Jalisco, Mexico
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Meckler G, Lindemulder S. Fever and Neutropenia in Pediatric Patients with Cancer. Emerg Med Clin North Am 2009; 27:525-44. [DOI: 10.1016/j.emc.2009.04.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lehrnbecher T, Creutzig U. Myeloid growth factors as anti-infective measures in children with leukemia and lymphoma. Expert Rev Hematol 2009; 2:159-72. [DOI: 10.1586/ehm.09.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Yee-Guardino S, Gowans K, Yen-Lieberman B, Berk P, Kohn D, Wang FZ, Danziger-Isakov L, Sabella C, Worley S, Pellett PE, Goldfarb J. Beta-herpesviruses in febrile children with cancer. Emerg Infect Dis 2008; 14:579-85. [PMID: 18394275 DOI: 10.3201/eid1404.070651] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2024] Open
Abstract
We conducted a cross-sectional study of beta-herpesviruses in febrile pediatric oncology patients (n = 30), with a reference group of febrile pediatric solid-organ transplant recipients (n = 9). One (3.3%) of 30 cancer patients and 3 (33%) of 9 organ recipients were PCR positive for cytomegalovirus. Four (13%) of 30 cancer patients and 3 (33%) of 9 transplant recipients had human herpesvirus 6B (HHV-6B) DNAemia, which was more common within 6 months of initiation of immune suppression (4 of 16 vs. 0 of 14 cancer patients; p = 0.050). HHV-6A and HHV-7 were not detected. No other cause was identified in children with HHV-6B or cytomegalovirus DNAemia. One HHV-6B-positive cancer patient had febrile disease with concomitant hepatitis. Other HHV-6B-positive children had mild "viral" illnesses, as did a child with primary cytomegalovirus infection. Cytomegalovirus and HHV-6B should be included in the differential diagnosis of febrile disease in children with cancer.
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Smith TJ, Khatcheressian J, Lyman GH, Ozer H, Armitage JO, Balducci L, Bennett CL, Cantor SB, Crawford J, Cross SJ, Demetri G, Desch CE, Pizzo PA, Schiffer CA, Schwartzberg L, Somerfield MR, Somlo G, Wade JC, Wade JL, Winn RJ, Wozniak AJ, Wolff AC. 2006 update of recommendations for the use of white blood cell growth factors: an evidence-based clinical practice guideline. J Clin Oncol 2006; 24:3187-205. [PMID: 16682719 DOI: 10.1200/jco.2006.06.4451] [Citation(s) in RCA: 1151] [Impact Index Per Article: 63.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To update the 2000 American Society of Clinical Oncology guideline on the use of hematopoietic colony-stimulating factors (CSF). UPDATE METHODOLOGY The Update Committee completed a review and analysis of pertinent data published from 1999 through September 2005. Guided by the 1996 ASCO clinical outcomes criteria, the Update Committee formulated recommendations based on improvements in survival, quality of life, toxicity reduction and cost-effectiveness. RECOMMENDATIONS The 2005 Update Committee agreed unanimously that reduction in febrile neutropenia (FN) is an important clinical outcome that justifies the use of CSFs, regardless of impact on other factors, when the risk of FN is approximately 20% and no other equally effective regimen that does not require CSFs is available. Primary prophylaxis is recommended for the prevention of FN in patients who are at high risk based on age, medical history, disease characteristics, and myelotoxicity of the chemotherapy regimen. CSF use allows a modest to moderate increase in dose-density and/or dose-intensity of chemotherapy regimens. Dose-dense regimens should only be used within an appropriately designed clinical trial or if supported by convincing efficacy data. Prophylactic CSF for patients with diffuse aggressive lymphoma aged 65 years and older treated with curative chemotherapy (CHOP or more aggressive regimens) should be given to reduce the incidence of FN and infections. Current recommendations for the management of patients exposed to lethal doses of total body radiotherapy, but not doses high enough to lead to certain death due to injury to other organs, includes the prompt administration of CSF or pegylated G-CSF.
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Affiliation(s)
- Thomas J Smith
- American Society of Clinical Oncology, Cancer Policy and Clinical Affairs, Alexandria, VA 22314, USA
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Chamberlain JD, Smibert E, Skeen J, Alvaro F. Prospective audit of treatment of paediatric febrile neutropenia in Australasia. J Paediatr Child Health 2005; 41:598-603. [PMID: 16398846 DOI: 10.1111/j.1440-1754.2005.00729.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Febrile neutropenia post-chemotherapy continues to impose a burden of morbidity and mortality on patients and families affected by childhood cancer, whereas these unplanned hospital admissions increase the financial cost of treating paediatric malignancies. There are currently no published national guidelines. This study comprises the first audit of current therapeutic practice in Australasia. METHODS Information was sought prospectively from the 12 paediatric oncology tertiary referral centres in Australia and New Zealand regarding treatment of febrile neutropenia episodes commencing between 11 March and 10 May 2002. RESULTS Data were returned on 127 episodes by nine centres. The median length of stay was 6 days and 18 different antibiotic regimens were implemented as first-line therapy. The median neutrophil count at the beginning and end of the febrile neutropenic episode was 0.0 x 10(9)/L (range 0.0 to 2.3 x 10(9)/L) and 0.7 x 10(9)/L (range 0.0 to 25.4 x 10(9)/L), respectively. Thirty per cent of episodes had positive blood cultures. Of these, 81% occurred in patients with tunnelled central venous catheters. The initial antimicrobial combination was changed in 61% of episodes. Outpatient antibiotics were used in 21% episodes after initial intravenous antimicrobial therapy. CONCLUSIONS The current practice in Australasia is consistent with international guidelines, although changes are made more frequently to first-line therapy than in previous published studies. The central venous catheters are associated with a much higher risk of bacteraemia and consideration should be given to increased use of implanted port systems.
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