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Barnbrock A, Möricke A, Barbaric D, Jones N, Koenig C, Moser R, Rohde M, Salvador C, Alten J, Elitzur S, Groll AH, Lehrnbecher T. Pneumocystis jirovecii pneumonia in paediatric acute lymphoblastic leukaemia: A report from the multi-international clinical trial AIEOP-BFM ALL 2009. Br J Haematol 2024; 204:2319-2323. [PMID: 38527954 DOI: 10.1111/bjh.19382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/15/2024] [Accepted: 02/22/2024] [Indexed: 03/27/2024]
Abstract
Pneumocystis jirovecii can cause life-threatening pneumonia (PjP), and patients with haematological malignancies are at high risk of this infection. Prophylactic measures have significantly decreased morbidity and mortality, but there is a paucity of contemporary data on the incidence and clinical course of PjP in well-defined and homogenous patient populations, such as children suffering from acute lymphoblastic leukaemia (ALL). In the multi-international trial AIEOP-BFM ALL2009, PjP was diagnosed in six children (incidence 1/1000) and was associated with insufficient prophylaxis in five of them. Although none of the patients died of PjP, the long-term impact of the infection is unclear.
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Affiliation(s)
- Anke Barnbrock
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Anja Möricke
- Department of Pediatrics, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Draga Barbaric
- Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Neil Jones
- Department of Pediatrics and Adolescent Medicine University Clinics Salzburg Salzburg Austria, Salzburg, Austria
| | - Christa Koenig
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Reinhard Moser
- Abteilung für Kinder- und Jugendheilkunde, Landeskrankenhaus Hochsteiermark Standort Leoben, Leoben, Austria
| | - Marius Rohde
- Department of Pediatric Oncology and Hematology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Christina Salvador
- Department für Kinder- und Jugendheilkunde, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Julia Alten
- Department of Pediatrics, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Sarah Elitzur
- Pediatric Hematology-Oncology, Schneider Children's Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andreas H Groll
- Infectious Disease Research Program, Department of Pediatric Hematology/Oncology and Center for Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany
| | - Thomas Lehrnbecher
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
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Chiu CY, Ching PR. Incidence of Pneumocystis pneumonia in Immunocompromised Patients without Human Immunodeficiency Virus with Intravenous Pentamidine Prophylaxis: A Systematic Review and Meta-Analysis. J Fungi (Basel) 2023; 9:jof9040406. [PMID: 37108861 PMCID: PMC10144649 DOI: 10.3390/jof9040406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Background: Trimethoprim-sulfamethoxazole (TMP-SMX) is a first-line Pneumocystis pneumonia pneumonia) (PCP) prophylaxis agent, but monthly intravenous pentamidine (IVP) is used in human immunodeficiency virus (HIV)-uninfected immunocompromised hosts because IVP is not associated with cytopenia and delayed engraftment. Method: We performed a systematic review and meta-analysis to estimate breakthrough PCP incidence and adverse reactions in HIV-uninfected immunocompromised patients receiving IVP. MEDLINE, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov were searched from their inception until 15 December 2022. Results: The pooled incidence of breakthrough PCP with IVP was 0.7% (95% CI, 0.3–1.4%, 16 studies, 3025 patients) and was similar when used as first-line prophylaxis (0.5%; 95% CI, 0.2–1.4%, 7 studies, 752 patients). The pooled incidence of adverse reactions was 11.3% (95% CI, 6.7–18.6%, 14 studies, 2068 patients). The pooled adverse event-related discontinuation was 3.7% (95% CI, 1.8–7.3%, 11 studies, 1802 patients), but was lower in patients receiving IVP monthly (2.0%; 95% CI 0.7–5.7%, 7 studies, 1182 patients). Conclusion: Monthly IVP is an appropriate second-line agent for PCP prophylaxis in certain non-HIV immunocompromised hosts, especially in patients with hematologic malignancies and hematopoietic stem cell transplant recipients. Using IVP for PCP prophylaxis as an alternative to oral TMP-SMX while patients are unable to tolerate enteral medication administration is feasible.
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Villeneuve S, Aftandilian C. Neutropenia and Infection Prophylaxis in Childhood Cancer. Curr Oncol Rep 2022; 24:671-686. [PMID: 35230594 PMCID: PMC8885776 DOI: 10.1007/s11912-022-01192-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Pediatric oncology patients frequently experience episodes of prolonged neutropenia which puts them at high risk for infection with significant morbidity and mortality. Here, we review the data on infection prophylaxis with a focus on both pharmacologic and ancillary interventions. This review does not include patients receiving hematopoietic stem cell transplantation. RECENT FINDINGS Patients with hematologic malignancies are at highest risk for infection. Bacterial and fungal prophylaxis decrease the risk of infection in certain high-risk groups. Ancillary measures such as ethanol locks, chlorhexidine gluconate baths, GCSF, IVIG, and mandatory hospitalization do not have enough data to support routine use. There is limited data on risk of infection and role of prophylaxis in patients receiving immunotherapy and patients with solid tumors. Patients with Down syndrome and adolescent and young adult patients may benefit from additional supportive care measures and protocol modifications. Consider utilizing bacterial and fungal prophylaxis in patients with acute myeloid leukemia or relapsed acute lymphoblastic leukemia. More research is needed to evaluate other supportive care measures and the role of prophylaxis in patients receiving immunotherapy.
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Affiliation(s)
- Stephanie Villeneuve
- Paediatric Haemotology/Oncology, Dalhousie University and the IWK Health Centre, 5850/5980 University Avenue, Halifax, NS, B3K 6R8, Canada
| | - Catherine Aftandilian
- Pediatric Hematology/Oncology, Stanford University, 1000 Welch Rd, Palo Alto, CA, 94304, USA.
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Mantadakis E. Pneumocystis jirovecii Pneumonia in Children with Hematological Malignancies: Diagnosis and Approaches to Management. J Fungi (Basel) 2020; 6:jof6040331. [PMID: 33276699 PMCID: PMC7761543 DOI: 10.3390/jof6040331] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that mostly affects children with suppressed cellular immunity. PJP was the most common cause of infectious death in children with acute lymphoblastic leukemia prior to the inclusion of cotrimoxazole prophylaxis as part of the standard medical care in the late 1980s. Children with acute leukemia, lymphomas, and those undergoing hematopoietic stem cell transplantation, especially allogeneic transplantation, are also at high risk of PJP. Persistent lymphopenia, graft versus host disease, poor immune reconstitution, and lengthy use of corticosteroids are significant risk factors for PJP. Active infection may be due to reactivation of latent infection or recent acquisition from environmental exposure. Intense hypoxemia and impaired diffusing capacity of the lungs are hallmarks of PJP, while computerized tomography of the lungs is the diagnostic technique of choice. Immunofluorescence testing with monoclonal antibodies followed by fluorescent microscopy and polymerase chain reaction testing of respiratory specimens have emerged as the best diagnostic methods. Measurement of (1-3)-β-D-glucan in the serum has a high negative predictive value in ruling out PJP. Oral cotrimoxazole is effective for prophylaxis, but in intolerant patients, intravenous and aerosolized pentamidine, dapsone, and atovaquone are effective alternatives. Ιntravenous cotrimoxazole is the treatment of choice, but PJP has a high mortality even with appropriate therapy.
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Affiliation(s)
- Elpis Mantadakis
- Department of Pediatrics, Hematology/Oncology Unit, University General Hospital of Alexandroupolis, Democritus University of Thrace, 68 100 Alexandroupolis, Thrace, Greece
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Geerlinks AV, Campigotto A, Science M, Gupta S. Impact of prophylaxis choice on risk of pneumocystis pneumonia in children with cancer: A case-control study. Eur J Cancer 2020; 140:71-75. [PMID: 33059195 DOI: 10.1016/j.ejca.2020.09.013] [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: 06/16/2020] [Revised: 08/06/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is a life-threatening opportunistic infection. Prophylaxis is recommended for patients with malignancies and trimethoprim-sulfamethoxazole (TMP-SMX) is the recommended first-line agent. Many paediatric patients receive second-line agents due to perceived adverse reactions from TMP-SMX. OBJECTIVE The objective of the study is to determine the risk of PJP in patients receiving TMP-SMX vs. second-line medications for prophylaxis. METHODS We conducted a retrospective, single centre, case-control study of paediatric oncology patients. Cases included children diagnosed with PJP by microscopy between 2000 and 2018 while being treated for a malignancy. Controls were matched by age, oncologic diagnosis, treatment protocol, phase of treatment and oncologic diagnosis date. For each case, up to 5 controls were randomly selected. The index date was the date of the PJP diagnosis for cases and the equivalent dummy date for controls. RESULTS Eleven cases with PJP were identified and matched with 50 controls. Six (55%) cases and 42 (84%) controls were on prophylaxis with TMP-SMX. The remaining patients received inhaled pentamidine (3 cases, 4 controls), dapsone (2 cases, 3 controls), or atovaquone (1 control). Myelosuppression was the most common reason to stop TMP-SMX. Cases with PJP were less likely to have been taking TMP-SMX in the 3 months before diagnosis when compared with controls (odds ratio: 0.15, 95% confidence interval: 0.01-0.97, p = 0.02). CONCLUSION TMP-SMX prophylaxis was associated with a lower risk of developing PJP compared with second-line treatments. Although alternate agents may be required in certain situations, efforts should be made to rechallenge with TMP-SMX when possible.
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Affiliation(s)
- Ashley V Geerlinks
- Division Hematology/Oncology, Department of Pediatrics, Hospital for Sick Children (SickKids), Toronto, Ontario, Canada, M5G 1X8.
| | - Aaron Campigotto
- Division of Microbiology, Department of Paediatric Laboratory Medicine, Hospital for Sick Children (SickKids), Toronto, Ontario, Canada, M5G 1X8; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada, M5S 1A8.
| | - Michelle Science
- Division of Infectious Diseases, Department of Pediatrics, Hospital for Sick Children (SickKids), Toronto, Ontario, Canada, M5G 1X8; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada, M5S 1A8.
| | - Sumit Gupta
- Division Hematology/Oncology, Department of Pediatrics, Hospital for Sick Children (SickKids), Toronto, Ontario, Canada, M5G 1X8; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada, M5S 1A8.
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Brown KS, Reed MD, Dalal J, Makii MD. Tolerability of Aerosolized Versus Intravenous Pentamidine for Pneumocystis jirovecii Pneumonia Prophylaxis in Immunosuppressed Pediatric, Adolescent, and Young Adult Patients. J Pediatr Pharmacol Ther 2020; 25:111-116. [PMID: 32071585 DOI: 10.5863/1551-6776-25.2.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Pentamidine is an antifungal that is used alternatively to sulfamethoxazole-trimethoprim for the prophylaxis and treatment of Pneumocystis jirovecii pneumonia (PJP). The primary objective of this study was to assess the tolerability of aerosolized versus intravenous pentamidine for PJP prophylaxis in pediatric, adolescent, and young adult immunosuppressed patients. Secondary objectives included comparing pentamidine formulation reaction to dosing frequency and diagnosis. METHODS This retrospective chart review used electronic medical record (EMR) data from patients at a tertiary care pediatric teaching institution from January 1, 2014, to January 1, 2017. Information used from the EMR included pentamidine dosing, ordering, and laboratory values. Inclusion criteria consisted of patients with a cancer diagnosis, hematopoietic stem cell transplant (HSCT) recipients, and renal transplant recipients who received pentamidine for PJP prophylaxis. RESULTS Ninety-six patients met inclusion criteria, of which 31 received aerosolized pentamidine. Ten of the 96 patients experienced a drug-related reaction to either aerosolized or intravenous pentamidine (p = 0.134). Nine of 10 patients who experienced a reaction received intravenous pentamidine versus 1 patient who received aerosolized pentamidine (p = 0.132). In those patients who reacted to pentamidine there was a higher incidence of reactions after subsequent administration (p = 0.039) and in patients with a blood cancer diagnosis (p = 0.042). CONCLUSIONS Data suggest that patients who receive aerosolized pentamidine may tolerate therapy better compared to intravenous administration. Additional studies involving larger numbers of pediatric, adolescent, and young adult patients are needed for stronger statistically significant clinical differences in tolerability of aerosolized versus intravenous pentamidine.
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Kruizinga MD, Bresters D, Smiers FJ, Lankester AC, Bredius RGM. The use of intravenous pentamidine for the prophylaxis of Pneumocystis pneumonia in pediatric patients. Pediatr Blood Cancer 2017; 64. [PMID: 28074607 DOI: 10.1002/pbc.26453] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 11/25/2016] [Accepted: 12/18/2016] [Indexed: 11/06/2022]
Abstract
Pneumocystis jiroveci pneumonia was common in the immunocompromised host before the widespread use of prophylaxis. When trimethoprim-sulfamethoxazole is not tolerated, prophylaxis with intravenous pentamidine (IVP) may be initiated. We performed a retrospective analysis of all pediatric patients who received IVP regarding efficacy, safety, and reason for initiation. Of 106 patients included in our analysis, one patient tested positive for Pneumocystis DNA. Adverse events were reported in 18% of IVP courses, and main reason for initiation was cytopenia (59%). We found IVP to be effective and safe, and recommend the use of IVP in pediatric patients in whom first-line prophylaxis is contraindicated.
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Affiliation(s)
- Matthijs D Kruizinga
- Department of Pediatric Immunology-Infections and Stem Cell Transplantation, Leiden University Medical Center, Leiden, The Netherlands
| | - Dorine Bresters
- Department of Pediatric Immunology-Infections and Stem Cell Transplantation, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans J Smiers
- Department of Pediatric Immunology-Infections and Stem Cell Transplantation, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan C Lankester
- Department of Pediatric Immunology-Infections and Stem Cell Transplantation, Leiden University Medical Center, Leiden, The Netherlands
| | - Robbert G M Bredius
- Department of Pediatric Immunology-Infections and Stem Cell Transplantation, Leiden University Medical Center, Leiden, The Netherlands
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Guidelines for the Prophylaxis of Pneumocystis jirovecii Pneumonia (PJP) in Children With Solid Tumors. J Pediatr Hematol Oncol 2017; 39:194-202. [PMID: 28267082 DOI: 10.1097/mph.0000000000000771] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Although it is well-established that children undergoing allogeneic stem cell transplants and treatment for leukemia should be offered prophylaxis against Pneumocystis jirovecii pneumonia, the risk for children with solid malignancies is less certain. This guideline has been developed with the aim of standardizing practice and optimizing the benefit versus risk of prophylactic medication in this group of patients. P. jirovecii pneumonia has a high mortality rate even with prompt antimicrobial treatment. Since prophylaxis with co-trimoxazole is safe, effective, and inexpensive, we suggest that all children with malignancies undergoing immunosuppressive therapy are offered prophylaxis unless there are clear contraindications.
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Safety and Effectiveness of Intravenous Pentamidine for Prophylaxis of Pneumocystis jirovecii Pneumonia in Pediatric Hematology/Oncology Patients. J Pediatr Hematol Oncol 2016; 38:e180-5. [PMID: 27164533 DOI: 10.1097/mph.0000000000000584] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PCP) is an opportunistic infection that can lead to significant morbidity and mortality in immunocompromised pediatric hematology/oncology patients. Trimethoprim/sulfamethoxazole is the gold standard for prophylaxis. Intravenous (IV) pentamidine is the preferred second-line agent for PCP prophylaxis at our institution and is used first-line under certain circumstances. The purpose of this study is to evaluate the effectiveness and safety of IV pentamidine for PCP prophylaxis in pediatric hematology/oncology patients. MATERIALS AND METHODS A retrospective analysis of pediatric hematology/oncology patients (N=121) who received ≥1 dose of IV pentamidine between January 2009 and July 2014 was conducted. Electronic health records were reviewed to determine baseline characteristics, rate of breakthrough PCP infection, characteristics of IV pentamidine use, and adverse events. The follow-up period was 6 months after the last reported IV pentamidine dose or the last recorded clinic visit/hospital admission. RESULTS No patients developed PCP during the entirety of their IV pentamidine course or during the follow-up period. Nineteen patients (16%) experienced adverse events and 5 of the 19 patients required discontinuation of IV pentamidine. CONCLUSIONS IV pentamidine is a safe, tolerable, and effective agent for PCP prophylaxis in pediatric hematology/oncology patients and may be considered a reasonable therapeutic alternative when trimethoprim/sulfamethoxazole cannot be used for PCP prophylaxis.
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IV pentamidine for Pneumocystis jiroveci pneumonia prophylaxis in pediatric allogeneic stem cell transplant patients. Bone Marrow Transplant 2016; 51:1394-1396. [PMID: 27214074 DOI: 10.1038/bmt.2016.133] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Maertens J, Cesaro S, Maschmeyer G, Einsele H, Donnelly JP, Alanio A, Hauser PM, Lagrou K, Melchers WJG, Helweg-Larsen J, Matos O, Bretagne S, Cordonnier C. ECIL guidelines for preventing Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients. J Antimicrob Chemother 2016; 71:2397-404. [PMID: 27550992 DOI: 10.1093/jac/dkw157] [Citation(s) in RCA: 175] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The 5th European Conference on Infections in Leukaemia (ECIL-5) meeting aimed to establish evidence-based recommendations for the prophylaxis of Pneumocystis jirovecii pneumonia (PCP) in non-HIV-infected patients with an underlying haematological condition, including allogeneic HSCT recipients. Recommendations were based on the grading system of the IDSA. Trimethoprim/sulfamethoxazole given 2-3 times weekly is the drug of choice for the primary prophylaxis of PCP in adults ( A-II: ) and children ( A-I: ) and should be given during the entire period at risk. Recent data indicate that children may benefit equally from a once-weekly regimen ( B-II: ). All other drugs, including pentamidine, atovaquone and dapsone, are considered second-line alternatives when trimethoprim/sulfamethoxazole is poorly tolerated or contraindicated. The main indications of PCP prophylaxis are ALL, allogeneic HSCT, treatment with alemtuzumab, fludarabine/cyclophosphamide/rituximab combinations, >4 weeks of treatment with corticosteroids and well-defined primary immune deficiencies in children. Additional indications are proposed depending on the treatment regimen.
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Affiliation(s)
- Johan Maertens
- Department of Haematology, Acute Leukaemia and Stem Cell Transplantation Unit, University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Simone Cesaro
- Department of Haematology, Oncoematologia Pediatrica, Policlinico G. B. Rossi, Verona, Italy
| | - Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Ernst-von-Bergmann Klinikum, Potsdam, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - J Peter Donnelly
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexandre Alanio
- Parasitology-Mycology Laboratory, Groupe Hospitalier Lariboisière Saint-Louis Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Diderot, Sorbonne Paris Cité, and Institut Pasteur, Unité de Mycologie Moléculaire, CNRS URA3012, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | - Philippe M Hauser
- Institute of Microbiology, Lausanne University Hospital and University, Lausanne, Switzerland
| | - Katrien Lagrou
- Department of Microbiology and Immunology, KU Leuven-University of Leuven, Leuven, Belgium and National Reference Center for Mycosis, Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jannik Helweg-Larsen
- Department of Infectious Diseases, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
| | - Olga Matos
- Medical Parasitology Unit, Group of Opportunistic Protozoa/HIV and Other Protozoa, Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Stéphane Bretagne
- Parasitology-Mycology Laboratory, Groupe Hospitalier Lariboisière Saint-Louis Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Diderot, Sorbonne Paris Cité, and Institut Pasteur, Unité de Mycologie Moléculaire, CNRS URA3012, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | - Catherine Cordonnier
- Department of Haematology, Henri Mondor Teaching Hospital, Assistance Publique-Hôpitaux de Paris, and Université Paris-Est-Créteil, Créteil, France
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Safe and Effective Prophylaxis with Bimonthly Intravenous Pentamidine in the Pediatric Hematopoietic Stem Cell Transplant Population. Pediatr Infect Dis J 2016; 35:135-41. [PMID: 26418240 DOI: 10.1097/inf.0000000000000946] [Citation(s) in RCA: 10] [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
BACKGROUND Without prophylaxis, Pneumocystis jiroveci pneumonia (PCP) develops in 5%-15% of pediatric hematopoietic stem cell transplant (HCT) patients with mortality above 50%. Trimethoprim-sulfamethoxazole is a standard PCP prophylaxis; pentamidine is frequently used as second-line prophylaxis because of trimethoprim-sulfamethoxazole's potential for cytopenias. Monthly intravenous (IV) pentamidine has variable efficacy with PCP infection rates of 0%-10% in pediatric patients, and higher breakthrough rates in those younger than 2 years. We hypothesized that bimonthly (twice monthly) pentamidine might have equivalent safety and improved efficacy; therefore, we conducted a retrospective analysis of bimonthly pentamidine PCP prophylaxis. METHODS We retrospectively reviewed records of all pediatric HCT patients who received bimonthly IV pentamidine between December 2006 and June 2013, and collected data regarding demographics, clinical course, prophylaxis rationale, laboratory values and adverse events. RESULTS Between December 2006 and June 2013, 111 pediatric HCT patients received bimonthly IV pentamidine (574 doses, 8758 patient-days); 31 patients were younger than 2 years at initiation. In the majority (53% of courses), pentamidine was initiated because of cytopenias. Fourteen patients (12.6% of patients, 2.4% of doses) experienced a side-effect prompting discontinuation, including 3 patients with infusion-related hypotension/anaphylaxis and 3 with acute pancreatic dysfunction. No patients [0% (95% confidence interval: 0-3.2)] developed PCP during or after bimonthly IV pentamidine prophylaxis. CONCLUSIONS Bimonthly IV pentamidine for PCP prophylaxis in the HCT pediatric population has comparable safety to monthly IV pentamidine and was highly effective, including in the very young. Bimonthly IV pentamidine should be considered in pediatric patients as second-line PCP prophylaxis.
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Boast A, Osowicki J, Cole T, Curtis N, Gwee A. Question 1: Co-trimoxazole dosing dilemma: what is the right dose? Arch Dis Child 2015; 100:1089-93. [PMID: 26408788 DOI: 10.1136/archdischild-2015-309100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 09/07/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Alison Boast
- Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Joshua Osowicki
- Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Theresa Cole
- Department of Allergy and Immunology, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Nigel Curtis
- Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia Murdoch Childrens Research Institute, Parkville, Victoria, Australia Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Amanda Gwee
- Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia Murdoch Childrens Research Institute, Parkville, Victoria, Australia Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
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Clark A, Hemmelgarn T, Danziger-Isakov L, Teusink A. Intravenous pentamidine for Pneumocystis carinii/jiroveci pneumonia prophylaxis in pediatric transplant patients. Pediatr Transplant 2015; 19:326-31. [PMID: 25712369 DOI: 10.1111/petr.12441] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 11/30/2022]
Abstract
SMX/TMP is the current gold standard for prophylaxis against PCP in immunocompromised pediatric patients. Currently, there are several second-line options for prophylaxis but many, including intravenous (IV) pentamidine, have not been reported to be as effective or as safe as SMX/TMP in the pediatric transplant population. This study is to determine the efficacy and safety of IV pentamidine in preventing PCP in pediatric transplant patients. A retrospective chart review was conducted to evaluate all transplant patients that received at least one dose of IV pentamidine from January 2010 to July 2013. The primary outcome, IV pentamidine efficacy, was evaluated by the incidence of PCP diagnosis for 28 days after the last dose of IV pentamidine if patient was transitioned to another agent for PCP prophylaxis. Patients on IV pentamidine for entire course of PCP prophylaxis were followed at least six months after discontinuation of IV pentamidine. The safety of IV pentamidine was assessed by the incidence of adverse events leading to pentamidine discontinuation. All data were analyzed using descriptive statistics. All transplant patients at CCHMC who had received IV pentamidine were reviewed, and 333 patients met inclusion criteria. The overall incidence of PCP was found to be 0.3% for pediatric transplant patients on pentamidine. Pentamidine was found to be safe, and the incidence of adverse events leading to discontinuation was 6% with the most common reason being tachycardia 2.1%. IV pentamidine is safe and effective as PCP prophylaxis in pediatric transplant patients with a PCP breakthrough rate of 0.3% (1 of 333 patients), and only 20 adverse events led to discontinuation. We recommend that IV pentamidine be considered as a second-line option in pediatric transplant patients who cannot tolerate SMX/TMP.
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Affiliation(s)
- Abigail Clark
- Pharmacy Department, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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[Medicinal prophylaxis during intensified immunosuppression in children and adolescents : part 2]. Z Rheumatol 2014; 72:896-909. [PMID: 23929242 DOI: 10.1007/s00393-013-1203-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The goal of modern antirheumatic therapy is to achieve an optimized disease control. This is individually achieved by an intensified immunosuppression (IS) frequently combining different immunosuppressive agents. Intensified IS should be accompanied by a standardized protocol to monitor immunological changes in the patient. This should include checklists (see Part 1 Screening during intensified IS in children and adolescents). An individual risk stratification according to the planned IS allows a prediction of infectious disease risks for the patient and, thus, individual infection prophylaxis. In addition, standardized management of patients with fever while receiving intensified IS may prevent further complications.
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Orgel E, Rushing T. Efficacy and tolerability of intravenous pentamidine isethionate for Pneumocystis jiroveci prophylaxis in a pediatric oncology population. Pediatr Infect Dis J 2014; 33:319-21. [PMID: 24030353 DOI: 10.1097/inf.0000000000000044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cancer therapy routinely requires Pneumocystis jiroveci prophylaxis. In those intolerant of trimethoprim/sulfamethoxazole, aerosolized pentamidine is convenient and effective. Intravenous pentamidine is often substituted in young children but its efficacy remains controversial. In this retrospective study of a large pediatric oncology cohort, we confirm intravenous pentamidine to be effective and well-tolerated as second-line prophylaxis across all ages.
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Affiliation(s)
- Etan Orgel
- From the *Jonathan Jaques Children's Cancer Center, Miller Children's Hospital Long Beach, Long Beach and †Children's Center for Cancer and Blood Disorders, Children's Hospital Los Angeles, Los Angeles, CA
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Tate ED, Pranzatelli MR, Verhulst SJ, Markwell SJ, Franz DN, Graf WD, Joseph SA, Khakoo YN, Lo WD, Mitchell WG, Sivaswamy L. Active comparator-controlled, rater-blinded study of corticotropin-based immunotherapies for opsoclonus-myoclonus syndrome. J Child Neurol 2012; 27:875-84. [PMID: 22378659 DOI: 10.1177/0883073811428816] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
To test the efficacy and safety of corticotropin-based immunotherapies in pediatric opsoclonus-myoclonus syndrome, 74 children received corticotropin alone or with intravenous immunoglobulin (groups 1 and 2, active controls); or both with rituximab (group 3) or cyclophosphamide (group 4); or with rituximab plus chemotherapy (group 5) or steroid sparers (group 6). There was 65% improvement in motor severity score across groups (P < .0001), but treatment combinations were more effective than corticotropin alone (P = .0009). Groups 3, 4, and 5 responded better than group 1; groups 3 and 5 responded better than group 2. The response frequency to corticotropin was higher than to prior corticosteroids (P < .0001). Fifty-five percent had adverse events (corticosteroid excess), more so with multiagents (P = .03); and 10% had serious adverse events. This study demonstrates greater efficacy of corticotropin-based multimodal therapy compared with conventional therapy, greater response to corticotropin than corticosteroid-based therapy, and overall tolerability.
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Affiliation(s)
- Elizabeth D Tate
- National Pediatric Myoclonus Center, and Departments of Neurology and Statistics and Research Consulting, Southern Illinois University School of Medicine, Springfield, IL 62794, USA.
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Saltzman RW, Albin S, Russo P, Sullivan KE. Clinical conditions associated with PCP in children. Pediatr Pulmonol 2012; 47:510-6. [PMID: 22009851 DOI: 10.1002/ppul.21577] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 08/16/2011] [Indexed: 01/15/2023]
Abstract
Pneumocystis jirovecii is a leading cause of opportunistic infections among the immune compromised. During the 1980s, attention focused on patients with HIV, however, with the advent of anti-retroviral therapy, we wished to revisit the question of underlying diseases associated with Pneumocystis pneumonia in children. We identified 80 cases from 1986 to 2006 and performed a retrospective chart review to identify clinical characteristics for each of the cases. HIV was the single most common associated underlying condition seen in this cohort, accounting for 39% of the cases overall, however, it was seen in just 15% of the cases since 1998. Transplant recipients and oncology patients together comprised another 39% of the cases, with 9% of cases attributed to primary immune deficiency and another 9% of cases associated with less well-recognized causes of susceptibility. This study documents the ongoing need for vigilance to diagnose Pneumocystis pneumonia in less well-recognized clinical scenarios.
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Affiliation(s)
- Rushani W Saltzman
- Division of Allergy Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Abstract
Pneumocystis pneumonia (PCP) can be life threatening for children receiving chemotherapy and immunosuppressive medication, including high-dose steroids. Although there are no current guidelines for prophylaxis in pediatric oncology patients, ongoing studies are evaluating the efficacy, side effects, ease of administration, and compliance of drugs used for PCP prophylaxis. Drugs currently being prescribed in practice include Bactrim, pentamidine, dapsone, and atovaquone. Bactrim remains superior for preventing PCP, but alternatives are being analyzed and investigated for those unable to tolerate Bactrim because of drug allergy or side effects. Educating patients and families about the importance of PCP prophylaxis and compliance should be a priority for all health care providers caring for children receiving immunosuppressive medications, including chemotherapy.
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Esbenshade AJ, Ho RH, Shintani A, Zhao Z, Smith LA, Friedman DL. Dapsone-induced methemoglobinemia: a dose-related occurrence? Cancer 2011; 117:3485-92. [PMID: 21246536 DOI: 10.1002/cncr.25904] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 12/06/2010] [Accepted: 12/06/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Dapsone, used for Pneumocystis jiroveci (PCP) prophylaxis, is associated with increased risk of methemoglobinemia. Absence of cytochrome b5 reductase enzyme activity causes congenital methemoglobinemia, but its role in dapsone-associated methemoglobinemia is unknown. The authors sought to elucidate drug-related risk factors for dapsone-associated methemoglobinemia in pediatric oncology patients, including contribution of cytochrome b5 reductase enzyme activity. METHODS Among 167 pediatric patients treated for hematologic malignancies or aplastic anemia who received dapsone for PCP prophylaxis, demographic and dapsone treatment data were retrospectively collected. Drug-related risk factors were evaluated by Cox proportional hazards, and in a cross-sectional subgroup of 40 patients, cytochrome b5 reductase enzyme activity was assessed. RESULTS Methemoglobinemia (median methemoglobin level = 9.0% [3.5-22.4]) was documented in 32 (19.8%) patients. There was a 73% risk reduction in methemoglobinemia with dosing ≥20% below the target dose of 2 mg/kg/d (hazard ratio [HR], 0.27; 95% confidence interval [CI], 0.09-0.78; P = .016), whereas methemoglobinemia risk was increased with dosing ≥20% above the target dose (HR, 6.25; 95% CI, 2.45-15.93; P < .001). Sex, body mass index, and age were not associated with increased risk. Cytochrome b5 reductase enzyme activity did not differ by methemoglobinemia status (median 8.6 IU/g hemoglobin [Hb]; [5.5-12.1] vs 9.1 IU/g Hb; [6.7-12.7]). No patient developed PCP on dapsone. CONCLUSIONS Methemoglobinemia occurred in almost 20% of pediatric oncology patients receiving dapsone for PCP prophylaxis. Higher dapsone dosing is associated with increased risk. A cross-sectionally acquired cytochrome b5 reductase enzyme activity level was not associated with methemoglobinemia risk. Studies are needed to define biologic correlates of methemoglobinemia and evaluate lower dapsone doses for PCP prophylaxis.
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Affiliation(s)
- Adam J Esbenshade
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN 37232, USA.
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Ohata Y, Ohta H, Hashii Y, Tokimasa S, Ozono K, Hara J. Intermittent oral trimethoprim/sulfamethoxazole on two non-consecutive days per week is effective as Pneumocystis jiroveci pneumonia prophylaxis in pediatric patients receiving chemotherapy or hematopoietic stem cell transplantation. Pediatr Blood Cancer 2009; 52:142-4. [PMID: 18819150 DOI: 10.1002/pbc.21774] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Pneumocystis jiroveci pneumonia (PCP) is a serious complication in patients receiving chemotherapy or hematopoietic stem cell transplantation. Current recommendations for trimethoprim-sulfamethoxazole (TMP-SMZ) dosing as PCP prophylaxis in immunocompromised patients are based on either daily dosing or dosing three consecutive days per week. We report our experience of prophylaxis with TMP-SMZ twice daily on two non-consecutive days per week in 145 immunocompromised children with hematologic disorders, cancer, or metabolic disorders following chemotherapy or hematopoietic stem cell transplantation. There were no breakthrough cases of PCP. We therefore conclude our prophylaxis regimen is effective against PCP in immunocompromised children.
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Affiliation(s)
- Yasuhisa Ohata
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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