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Peters S, Adler M, Rossoff J. Outcomes of Children Discharged Prior to Absolute Neutrophil Count Recovery After Admission for Febrile Neutropenia. J Pediatr Hematol Oncol 2023; 45:e948-e952. [PMID: 37700440 DOI: 10.1097/mph.0000000000002757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/18/2023] [Indexed: 09/14/2023]
Abstract
Febrile neutropenia (FN) management in pediatric oncology patients traditionally necessitates inpatient admission until evidence of bone marrow recovery. Discharge before count recovery may be a way to safely reduce the length of hospitalizations for select patients. A chart review was conducted of patients admitted for FN at one tertiary care children's hospital, where the standard is to discharge well-appearing patients after 48 hours of negative cultures if afebrile for at least 24 hours, irrespective of absolute neutrophil count (ANC). Patients with ANC <500 at discharge were identified as early discharges, and data were collected with respect to rates of readmission and infectious complications in this cohort. Among 1230 FN encounters, 765 (62%) were early discharges. 122 patients (15.9%) were readmitted within 7 days. Patients with acute myeloid leukemia and ANC <100 at discharge were more likely to be readmitted. Of the early discharges, only 10 (1.31%) were readmitted with positive blood cultures and 5 (0.7%) were admitted to the pediatric intensive care unit within 24 hours of readmission. Routine discharge before ANC recovery allows for short hospital stays with low rates of readmission, infectious complications, and critical illness for pediatric oncology patients. This safe and beneficial policy should be considered at other institutions.
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Affiliation(s)
- Sarah Peters
- Department of Pediatrics, Northwestern University Feinberg School of Medicine
| | - Mark Adler
- Department of Pediatrics, Northwestern University Feinberg School of Medicine
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital
| | - Jenna Rossoff
- Department of Pediatrics, Northwestern University Feinberg School of Medicine
- Division of Hematology/Oncology/Neuro-Oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital, Chicago, IL
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2
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Adekunle MO, Davidson A, Hendricks M. Risk factors and predictors of adverse outcomes of in paediatric febrile neutropenia. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2022. [DOI: 10.4102/sajo.v6i0.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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3
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Lavieri L, Koenig C, Bodmer N, Agyeman PKA, Scheinemann K, Ansari M, Roessler J, Ammann RA. Predicting fever in neutropenia with safety-relevant events in children undergoing chemotherapy for cancer: The prospective multicenter SPOG 2015 FN Definition Study. Pediatr Blood Cancer 2021; 68:e29253. [PMID: 34310027 DOI: 10.1002/pbc.29253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/11/2021] [Accepted: 07/12/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Fever in neutropenia (FN) remains a frequent complication in pediatric patients undergoing chemotherapy for cancer. Preventive strategies, like primary antibiotic prophylaxis, need to be evidence-based. PROCEDURE Data on pediatric patients with any malignancy from the prospective multicenter SPOG 2015 FN Definition Study (NCT02324231) were analyzed. A score predicting the risk to develop FN with safety-relevant events (SRE; bacteremia, severe sepsis, intensive care unit admission, death) was developed using multivariate mixed Poisson regression. Its predictive performance was assessed by internal cross-validation and compared with the performance of published rules. RESULTS In 238 patients, 318 FN episodes were recorded, including 53 (17%) with bacteremia and 68 (21%) with SRE. The risk-prediction score used three variables: chemotherapy intensity, defined according to the expected duration of severe neutropenia, time since diagnosis, and type of malignancy. Its cross-validated performance, assessed by the time needed to cover (TNC) one event, exceeded the performance of published rules. A clinically useful score threshold of ≥11 resulted in 2.3% time at risk and 4.1 months TNC. Using external information on efficacy and timing of intermittent antibiotic prophylaxis, 4.3 months of prophylaxis were needed to prevent one FN with bacteremia, and 5.2 months to prevent one FN with SRE, using a threshold of ≥11. CONCLUSIONS This score, based on three routinely accessible characteristics, accurately identifies pediatric patients at risk to develop FN with SRE during chemotherapy. The score can help to design clinical decision rules on targeted primary antibiotic prophylaxis and corresponding efficacy studies.
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Affiliation(s)
- Luana Lavieri
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christa Koenig
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Bodmer
- Pediatric Oncology, University Children's Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katrin Scheinemann
- Pediatric Hematology/Oncology, Department of Pediatrics, Kantonsspital Aarau, Aarau, Switzerland.,University of Basel, Basel, Switzerland.,Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
| | - Marc Ansari
- Pediatric Hematology/Oncology, Department of Women, Child and Adolescent, University Hospital of Geneva, Geneva, Switzerland.,Department of Pediatrics, Gynecology, and Obstetrics, Cansearch Research Platform of Pediatric Oncology and Hematology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jochen Roessler
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roland A Ammann
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Kinderaerzte KurWerk, Burgdorf, Switzerland
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Lima MAF, de Sá Rodrigues KE, Vanucci MF, da Silva PLL, Baeta T, Oliveira IP, Romanelli RMDC. Bloodstream infection in pediatric patients with febrile neutropenia induced by chemotherapy. Hematol Transfus Cell Ther 2021:S2531-1379(21)01308-0. [PMID: 34866034 DOI: 10.1016/j.htct.2021.08.005] [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: 06/01/2021] [Revised: 07/22/2021] [Accepted: 08/02/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Febrile neutropenia (FN) is a serious complication of cancer chemotherapy. The present study aimed to identify risk factors for documented infection in pediatric patients with FN and cancer. METHODS This prospective cohort study included patients under 18 years from 2016 to 2018. Infection was defined according to the Centers for Disease Control and Prevention criteria. RESULTS A total of 172 febrile neutropenic episodes were evaluated. From univariate analysis, the risk factors were: female gender; monocyte count < 100 cell/mm³, platelets < 50,000, C-reactive protein (CRP) > 90 mg/dl and hemoglobin < 7mg/dl at the onset of an episode; two or more episodes of FN, and; fever onset; positive blood culture at the fever onset. Independent risk factors according to the multivariate analysis were: CRP at the onset of a febrile episode > 90mg/dl, fever onset and first blood culture with a positive result. The lowest probability of infection was related to first episode and to platelets > 50,000 at the onset of fever. CONCLUSION A CRP > 90 at the onset of a febrile episode, platelets < 50,000, second episode or more, first fever episode during hospitalization and positive first blood culture were found to be associated with a higher risk of infection and they could be useful for the establishment of risk scores for infection in neutropenic children.
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Affiliation(s)
| | | | | | | | - Thais Baeta
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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Schlenker L, Manworren RCB. Timing of Pegfilgrastim: Association with Febrile Neutropenia in a Pediatric Solid and CNS Tumor Population. J Pediatr Oncol Nurs 2021; 38:375-384. [PMID: 34402328 DOI: 10.1177/10434542211037729] [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: 11/17/2022] Open
Abstract
Background: While recommended timing of pegfilgrastim administration is ≥24 h after chemotherapy, patient barriers to next day administration, available adult evidence, and pharmacokinetic data have led to earlier administration in some pediatric patients with solid and central nervous system tumors. The purpose of this study was to compare patient outcomes by timing of pegfilgrastim after chemotherapy. Methods: A retrospective chart review examined timing of 932 pegfilgrastim administrations to 182 patients, 0-29 years of age. The primary outcome was febrile neutropenia (FN); the secondary outcome was neutropenic delays (ND) ≥7 days to next chemotherapy cycle. To account for multiple pegfilgrastim administrations per patient, a generalized mixed model was used with a logit link for the dichotomous outcomes (FN & ND), timing as the dichotomous independent variable, and random effect for patient. Results: FN occurred in 196 of 916 cycles (21.4%); and ND in 19 of 805 cycles (2.4%). The fixed effect of pegfilgrastim administration < or ≥24 h after chemotherapy was not significant, p = .50; however, earlier or later than 20 h was significant, p = .005. FN odds were significantly higher when pegfilgrastim was given <20 h (OR 1.78, 95% CI: 1.19-2.65) after chemotherapy, which may be attributable to differences in chemotherapy toxicity regardless of pegfilgrastim timing. Discussion: While attempts should be made to administer pegfilgrastim ≥24 h after chemotherapy, if barriers exist, modified timing based on individual patient characteristics should be considered. Prospective randomized trials are needed to identify lower risk patients for early pegfilgrastim administration.
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Affiliation(s)
- Laura Schlenker
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Renee C B Manworren
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Pediatrics, 12244Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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6
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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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7
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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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8
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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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9
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Brack E, Wagner S, Stutz-Grunder E, Agyeman PKA, Ammann RA. Temperatures, diagnostics and treatment in pediatric cancer patients with fever in neutropenia, NCT01683370. Sci Data 2020; 7:156. [PMID: 32457478 PMCID: PMC7250883 DOI: 10.1038/s41597-020-0504-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/22/2020] [Indexed: 11/18/2022] Open
Abstract
In pediatric oncology, there is no evidence-based definition of the temperature limit defining fever (TLDF), which itself is essential for the definition of fever in chemotherapy-induced severe neutropenia (FN). Lowering the TLDF can increase the number of FN episodes diagnosed. This prospective, single center observational study collected data on all temperature measurements, complete blood counts (CBCs), and measures of diagnostics and therapy performed at and after FN diagnosis in pediatric oncology patients using a high standard TLDF (39 °C ear temperature). In 45 FN episodes in 20 patients, 3391 temperature measurements and 318 CBCs, plus information on antibiotics, anti-fungal therapy, antipyretics, blood cultures taken and on discharge were collected. These data can mainly be used to study the influence of virtually lowering the TLDF on diagnostic measures, treatment and length of hospitalization in pediatric FN, which in turn are directly related to costs of FN therapy, and quality of life. This approach can be expanded to include as well different definitions of neutropenia. Measurement(s) | body temperature trait • Blood Cell Count • Diagnostics, Cancer • therapy | Technology Type(s) | Thermometer Device • complete blood cell count • Observational study | Factor Type(s) | day and time • outcome | Sample Characteristic - Organism | Homo sapiens | Sample Characteristic - Environment | hospital |
Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.12118473
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Affiliation(s)
- Eva Brack
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Freiburgstrasse 15, 3010, Bern, Switzerland
| | - Stéphanie Wagner
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Freiburgstrasse 15, 3010, Bern, Switzerland.,Division of Pediatric Nephrology, Department of Pediatrics, Inselspital, Bern University Hospital, Freiburgstrasse 15, 3010, Bern, Switzerland
| | - Eveline Stutz-Grunder
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Freiburgstrasse 15, 3010, Bern, Switzerland.,Department of Pediatric Oncology, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, Freiburgstrasse 15, 3010, Bern, Switzerland
| | - Roland A Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Freiburgstrasse 15, 3010, Bern, Switzerland.
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10
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Phillips B, Morgan JE, Haeusler GM, Riley RD. Individual participant data validation of the PICNICC prediction model for febrile neutropenia. Arch Dis Child 2020; 105:439-445. [PMID: 31690548 PMCID: PMC7212933 DOI: 10.1136/archdischild-2019-317308] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 09/20/2019] [Accepted: 10/18/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Risk-stratified approaches to managing cancer therapies and their consequent complications rely on accurate predictions to work effectively. The risk-stratified management of fever with neutropenia is one such very common area of management in paediatric practice. Such rules are frequently produced and promoted without adequate confirmation of their accuracy. METHODS An individual participant data meta-analytic validation of the 'Predicting Infectious ComplicatioNs In Children with Cancer' (PICNICC) prediction model for microbiologically documented infection in paediatric fever with neutropenia was undertaken. Pooled estimates were produced using random-effects meta-analysis of the area under the curve-receiver operating characteristic curve (AUC-ROC), calibration slope and ratios of expected versus observed cases (E/O). RESULTS The PICNICC model was poorly predictive of microbiologically documented infection (MDI) in these validation cohorts. The pooled AUC-ROC was 0.59, 95% CI 0.41 to 0.78, tau2=0, compared with derivation value of 0.72, 95% CI 0.71 to 0.76. There was poor discrimination (pooled slope estimate 0.03, 95% CI -0.19 to 0.26) and calibration in the large (pooled E/O ratio 1.48, 95% CI 0.87 to 2.1). Three different simple recalibration approaches failed to improve performance meaningfully. CONCLUSION This meta-analysis shows the PICNICC model should not be used at admission to predict MDI. Further work should focus on validating alternative prediction models. Validation across multiple cohorts from diverse locations is essential before widespread clinical adoption of such rules to avoid overtreating or undertreating children with fever with neutropenia.
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Affiliation(s)
- Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, UK .,Leeds Children's Hospital, Leeds, UK
| | - Jessica Elizabeth Morgan
- Centre for Reviews and Dissemination, University of York, York, UK,Leeds Children's Hospital, Leeds, UK
| | - Gabrielle M Haeusler
- Infectious Diseases and Infection Control, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Richard D Riley
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
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Saito S, Yanagisawa R, Minami K, Uchida E, Watanabe T, Komori K, Kurata T, Nakamura T, Sakashita K. Prophylactic piperacillin administration in pediatric patients with solid tumors following different intensities of chemotherapy. Pediatr Int 2020; 62:158-168. [PMID: 31846519 DOI: 10.1111/ped.14103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 12/04/2019] [Accepted: 12/12/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Prophylactic antibiotics decrease mortality and morbidity in patients with hematological malignancies following intensive chemotherapy. However, the efficacy of prophylactic antibiotics for pediatric patients with solid tumors remains unclear. METHODS We retrospectively assessed 103 neutropenic periods from 26 patients with neuroblastoma or brain tumors following three different intensity chemotherapy regimens (05A3, A, and B). While piperacillin was intravenously administered as prophylaxis (PIPC prophylaxis group), the historical control group received no prophylaxis. As patients exhibited a variable degree of myelosuppression based on the intensity of the chemotherapy regimen, we separately evaluated the frequency and severity of febrile neutropenia (FN) in each regimen. RESULTS Following intensive chemotherapy, we observed a significantly lower frequency of FN in the PIPC prophylaxis group compared with the historical control group in both regimen 05A3 (20% vs 65%; P = 0.01) and regimen A (56% vs 93%; P = 0.02). We also observed a shorter duration of fever, lower maximum fever, and lower C-reactive protein levels in the PIPC prophylaxis group compared with the historical control group after regimens 05A3 and A. Conversely, the frequency and severity of FN were not different between the two groups after moderate-intensity chemotherapy (regimen B). However, a longitudinal routine surveillance study of Pseudomonas aeruginosa also indicated a reduction in the susceptibility to PIPC throughout the study period. CONCLUSIONS Although PIPC prophylaxis might provide an advantage for severe neutropenia in pediatric patients with solid tumors, there is concern regarding bacterial resistance to antibiotics. Therefore, further careful examination is necessary for adaptation.
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Affiliation(s)
- Shoji Saito
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan.,Life Science Research Center, Nagano Children's Hospital, Azumino, Japan.,Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryu Yanagisawa
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan.,Division of Blood Transfusion, Shinshu University Hospital, Matsumoto, Japan.,Center for Advanced Cell Therapy, Shinshu University Hospital, Matsumoto, Japan
| | - Kisei Minami
- Department of General Pediatrics, Nagano Children's Hospital, Azumino, Japan
| | - Eriko Uchida
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Tatsuo Watanabe
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Kazutoshi Komori
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Takashi Kurata
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Tomohiko Nakamura
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan
| | - Kazuo Sakashita
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan.,Life Science Research Center, Nagano Children's Hospital, Azumino, Japan
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12
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Zermatten MG, Koenig C, von Allmen A, Agyeman P, Ammann RA. Episodes of fever in neutropenia in pediatric patients with cancer in Bern, Switzerland, 1993-2012. Sci Data 2019; 6:180304. [PMID: 30644854 PMCID: PMC6335615 DOI: 10.1038/sdata.2018.304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/26/2018] [Indexed: 11/09/2022] Open
Abstract
Fever in neutropenia (FN) is the most frequent potentially life threatening complication of chemotherapy for cancer. Prediction of the risk to develop complications, integrated into clinical decision rules, would allow for risk-stratified treatment of FN. This retrospective, single center cohort study in pediatric patients diagnosed with cancer before 17 years, covered two decades, 1993 to 2012. In total, 703 FN episodes in 291 patients with chemotherapy (maximum per patient, 9) were reported here. Twenty-nine characteristics of FN were collected: 6 were patient- and cancer-related, 8 were characteristics of history, 8 of clinical examination, and 7 laboratory results in peripheral blood, all known at FN diagnosis. In total 28 FN outcomes were assessed: 8 described treatment of FN, 6 described microbiologically defined infections (MDI), 4 clinically defined infections, 4 were additional clinical composite outcomes, and 6 outcomes were related to discharge. These data can mainly be used to study FN characteristics and their association with outcomes over time and between centers, and for derivation and external validation of clinical decision rules.
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Affiliation(s)
- Maxime G. Zermatten
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Philipp Agyeman
- 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
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Making Improvements in the ED: Does ED Busyness Affect Time to Antibiotics in Febrile Pediatric Oncology Patients Presenting to the Emergency Department? Pediatr Emerg Care 2018; 34:310-316. [PMID: 27749799 DOI: 10.1097/pec.0000000000000882] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Febrile neutropenic pediatric patients are at heightened risk for serious bacterial infections, and rapid antibiotic administration (in <60 minutes) improves survival. Our objectives were to reduce the time-to-antibiotic (TTA) administration and to evaluate the effect of overall emergency department (ED) busyness on TTA. METHODS This study was a quality improvement initiative with retrospective chart review to reduce TTA in febrile children with underlying diagnosis of cancer or hematologic immunodeficiency who visited the pediatric ED. A multidisciplinary clinical practice guideline (CPG) was implemented to improve TTA. The CPG's main focus was delivery of antibiotics before availability of laboratory data. We collected data on TTA during baseline and intervention periods. Concurrent patient arrivals to the ED per hour served as a proxy of busyness. Time to antibiotic was compared with the number of concurrent arrivals per hour. Analyses included scatter plot and regression analysis. RESULTS There were 253 visits from October 1, 2010 to March 30, 2012. Median TTA administration dropped from 207 to 89 minutes (P < 0.001). Eight months after completing all intervention periods, the median had dropped again to 44 minutes with 70% of patients receiving antibiotics within 60 minutes of ED arrival. There was no correlation between concurrent patient arrivals and TTA administration during the historical or intervention periods. CONCLUSIONS Implementation of a CPG and process improvements significantly reduced median TTA administration. Total patient arrivals per hour as a proxy of ED crowding did not affect TTA administration. Our data suggest that positive improvements in clinical care can be successful despite fluctuations in ED patient volume.
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von Allmen AN, Zermatten MG, Leibundgut K, Agyeman P, Ammann RA. Pediatric patients at risk for fever in chemotherapy-induced neutropenia in Bern, Switzerland, 1993-2012. Sci Data 2018. [PMID: 29534058 PMCID: PMC5849221 DOI: 10.1038/sdata.2018.38] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Fever in neutropenia (FN) is the most frequent potentially life threatening complication of chemotherapy for cancer. Prediction of the risk to develop FN during chemotherapy would allow for targeted prophylaxis. This retrospective, single centre cohort study in pediatric patients diagnosed with cancer before 17 years covered two decades, 1993 to 2012. The 583 (73%) of 800 patients diagnosed with cancer who had received chemotherapy were studied here. Data on 2113 observation periods was collected, defined by stable combinations of 11 predefined characteristics potentially associated with FN. They covered 692 years of cumulative chemotherapy exposure time, during which 712 FN episodes were diagnosed, 154 (22%) of them with bacteremia. The risk to develop FN and FN with bacteremia remained stable over time. These data can mainly be used to study FN risks over time and between centers, and to derive or externally validate FN risk prediction rules.
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Affiliation(s)
- Annina N von Allmen
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Maxime G Zermatten
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Kurt Leibundgut
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Philipp Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Roland A Ammann
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
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15
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Wagner S, Brack EK, Stutz-Grunder E, Agyeman P, Leibundgut K, Teuffel O, Ammann RA. The influence of different fever definitions on diagnostics and treatment after diagnosis of fever in chemotherapy-induced neutropenia in children with cancer. PLoS One 2018; 13:e0193227. [PMID: 29462193 PMCID: PMC5819814 DOI: 10.1371/journal.pone.0193227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 02/07/2018] [Indexed: 11/18/2022] Open
Abstract
Background There is no evidence-based definition of the temperature limit defining fever (TLDF) in children with neutropenia. Lowering the TLDF is known to increase the number of episodes of fever in neutropenia (FN). This study aimed to investigate the influence of a lower versus standard TLDF on diagnostics and therapy. Methods In a single pediatric cancer center using a high standard TLDF (39°C tympanic-temperature) patients were observed prospectively (NCT01683370). The effect of applying lower TLDFs (range 37.5°C to 38.9°C) versus 39.0°C on these measures was simulated in silicon. Results In reality, 45 FN episodes were diagnosed. Of 3391 temperatures measured, 193 were ≥39.0°C, and 937 ≥38.0°C. For persisting fever ≥24 hours, additional blood cultures were taken in 31 (69%) episodes in reality. This number decreased to 22 (49%) when applying 39.0°C, and increased to 33 for 38.0°C (73%; plus 11 episodes; plus 24%). For persisting fever ≥48 hours, i.v.-antibiotics were escalated in 25 (56%) episodes. This number decreased to 15 (33%) when applying 39.0°C, and increased to 26 for 38.0°C (58%; plus 11 episodes; plus 24%). For persisting fever ≥120 hours, i.v.-antifungals were added in 4 (9%) episodes. This number increased to 6 (13%) by virtually applying 39.0°C, and to 11 for 38.0°C (24%; plus 5 episodes; plus 11%). The median length of stay was 5.7 days (range, 0.8 to 43.4). In 43 episodes with hospital discharge beyond 24 hours, applying 38.0°C led to discharge delay by ≥12 hours in 24 episodes (56%; 95% CI, 40 to 71), with a median delay of 13 hours, and a cumulative delay of 68 days. Conclusion Applying a low versus standard TLDF led to relevant increases of diagnostics, antimicrobial therapy, and length of stay. The differences between management in reality versus simply applying 39.0° as TLDF reflect the important impact of clinical assessment.
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Affiliation(s)
- Stéphanie Wagner
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eva K. Brack
- Department of Infectious Disease and Cancer Research, Children´s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Eveline Stutz-Grunder
- Department of Pediatric Oncology, Children´s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Philipp Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kurt Leibundgut
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Oliver Teuffel
- Division of Oncology, Medical Services of the Statutory Health Insurance Baden-Württemberg, Tübingen, Germany
| | - Roland A. Ammann
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
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Risk-adapted approach for fever and neutropenia in paediatric cancer patients – A national multicentre study. Eur J Cancer 2016; 53:16-24. [DOI: 10.1016/j.ejca.2015.10.065] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/25/2015] [Accepted: 10/27/2015] [Indexed: 11/18/2022]
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Delebarre M, Macher E, Mazingue F, Martinot A, Dubos F. Which decision rules meet methodological standards in children with febrile neutropenia? Results of a systematic review and analysis. Pediatr Blood Cancer 2014; 61:1786-91. [PMID: 24975886 DOI: 10.1002/pbc.25106] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 04/23/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Clinical decision rules (CDRs) have sought to identify the few children with chemotherapy-induced febrile neutropenia (FN) really at risk of severe infection to reduce the invasive procedures and costs for those at low risk. Several reports have shown that most rules do not perform well enough to be clinically useful. Our objective was to analyze the derivation methods and validation procedures of these CDRs. PROCEDURE A systematic review using Medline, Ovid, Refdoc, and the Cochrane Library through December 2012 searched for all CDRs predicting the risk of severe infection and/or complications in children with chemotherapy-induced FN. Their methodological quality was analyzed by 17 criteria for deriving and validating a CDR identified in the literature. The criteria published by the Evidence Based Medicine Working Group were applied to the published validations of each CDR to assess their level of evidence. RESULTS The systematic research identified 612 articles and retained 12 that derived CDRs. Overall, the CDRs met a median of 65% of the methodological criteria. The criteria met least often were that the rule made clinical sense, or described the course of action, or that the variables and the CDR were reproducible. Only one CDR, developed in South America, met all methodological criteria and provided the highest level of evidence; unfortunately it was not reproducible in Europe. CONCLUSION Only one CDR developed for children with FN met all methodological standards and reached the highest level of evidence.
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Affiliation(s)
- Mathilde Delebarre
- Pediatric Emergency Unit and Infectious Diseases, UDSL, Lille University Hospital, Lille, France; EA2694, UDSL, Lille University Hospital, Lille, France; Pediatric Hematology Unit, UDSL, Lille University Hospital, Lille, France
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Karakurt DG, Demirsoy U, Corapcioglu F, Oncel S, Karadogan M, Arisoy ES. Do proinflammatory cytokine levels predict serious complication risk of infection in pediatric cancer patients? Pediatr Hematol Oncol 2014; 31:415-24. [PMID: 24499434 DOI: 10.3109/08880018.2013.848387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Determination of risk of severe bacterial infection complication in children with cancer is important to diminish the cost of hospitalization and therapy. In this study, children with cancer (leukemia excluded) were evaluated for risk of severe infection complication, success of therapy and the relation between clinical and inflammatory parameters during neutropenic fever attacks. Children who fulfilled the criteria of neutropenic fever with cancer were enrolled in the study. During admission, together with clinical and laboratory parameters; interleukin-6, interleukin-8, soluble tumor necrosis factor receptor II, and soluble interleukin 2 reseptor ve procalcitonin levels were detected. Empirical therapy was started with piperacillin/tazobactam and relation between the inflammatory cytokine levels and therapy response parameters were evaluated. The study population included 31 children and 50 neutropenic attacks were studied. In 48% of the attacks, absolute neutrophile count was >100/mm(3) and infectious agents were shown microbiologically in 12% of the attacks. In the study group with piperacillin/tazobactam monotherapy, the success rate without modification was 58%. In the therapy modified group mean duration of fever, antibiotherapy and hospitalization were significantly longer than the group without modification. Inflammatory cytokines' levels during admission (interleukin-6, interleukin-8, soluble tumor necrosis factor reseptor II) were higher in patients with fever >3 days and in multiple regression analysis, it has been shown that they have a determinative role on fever control time. Other cytokines did not show any significant relationship with risk of severe bacterial infection complication and success of therapy.
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Kirby J, Dolendo M, Guimera D, Castillo C, Johnson KM, Mzayek F, Nolan VG, Relyea G, Caniza MA. Predictors of wait-time for antibiotic initiation and association of wait-time with hospital length of stay and ICU admission among children with cancer at the Southern Philippines Medical Center. Pediatr Blood Cancer 2014; 61:680-6. [PMID: 24660227 DOI: 10.1002/pbc.24836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Expedited antibiotic administration improves the survival of children with cancer and infection. A 1-hour antibiotic wait-time (AWT) post-hospital arrival is a quality-of-care bench mark in healthcare. However, multiple factors preclude achieving this goal in developing countries. Predictors of AWT and its association with hospital length of stay (LOS) and intensive care unit (ICU) admission at the Southern Philippines Medical Center (SPMC) were identified. PROCEDURES Health and socioeconomic characteristics of 55 children in 92 admissions who required antibiotics were reviewed;and SPMC care providers about institutional capacity and response to suspected infection were surveyed. RESULTS The mean total AWT was 3 days and 15 hours. For admissions of established patients, mean total AWT and mean LOS were approximately half that for new patients. Admissions from high-income households waited an average 44% less for antibiotics and were discharged 43% sooner than those from medium-income households. Admissions from residence owner families waited 31% less to receive antibiotics, and total AWT for admissions of patients with no insurance was 32% less than for those with insurance. The likelihood of ICU admission increased 20% with every 1-day increase in total AWT (95% CI: 1.021.42). Only 59% of nurses recognized fever as an emergency. CONCLUSIONS AWT is complex and multifactorial; it may be reduced by educating parents and care providers about infection and infection control and improving the availability of antibiotics and associated supplies. These interventions will most likely reduce ICU admissions and possibly LOS and increase the survival of pediatric oncology patients at SPMC.
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Affiliation(s)
- Jeannette Kirby
- School of Public Health; University of Memphis; Memphis Tennessee
| | - Mae Dolendo
- Children's Cancer and Blood Disease Unit of the Southern Philippines Medical Center; Davao City Philippines
| | - Don Guimera
- Department of Infectious Diseases; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Czarina Castillo
- Children's Cancer and Blood Disease Unit of the Southern Philippines Medical Center; Davao City Philippines
| | - Kyle M. Johnson
- Department of Infectious Diseases; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Fawaz Mzayek
- School of Public Health; University of Memphis; Memphis Tennessee
| | - Vikki G. Nolan
- School of Public Health; University of Memphis; Memphis Tennessee
| | - George Relyea
- School of Public Health; University of Memphis; Memphis Tennessee
| | - Miguela A. Caniza
- Department of Infectious Diseases; St. Jude Children's Research Hospital; Memphis Tennessee
- International Outreach Program; St. Jude Children's Research Hospital; Memphis TN
- Department of Pediatrics; College of Medicine; University of Tennessee Health Science Center; Memphis Tennessee
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af Sandeberg M, Wettergren L, Björk O, Arvidson J, Johansson E. Does school attendance during initial cancer treatment in childhood increase the risk of infection? Pediatr Blood Cancer 2013; 60:1307-12. [PMID: 23596132 DOI: 10.1002/pbc.24510] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 02/04/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND The present study aimed to investigate the relationship between school attendance and infection requiring antimicrobial treatment in children undergoing treatment for cancer. PROCEDURE A national cohort of children aged 7-16 years undergoing cancer treatment was assessed during two observation periods of 19 days each, 1 month (n = 89) and 2.5 months (n = 89) poststart of treatment. Children free from infection at start of each observation period were included. Multivariable logistic regression analyses were performed including factors potentially associated with start of antimicrobial treatment. RESULTS Twenty-seven (30%) children started antimicrobial treatment during the first observation period. Factors associated with an increased risk of starting antimicrobial treatment were diagnosed with sarcoma (OR = 24.37, P = 0.002) or non-Hodgkin lymphoma (OR = 17.57, P = 0.025), having neutropenia (OR = 5.92, P = 0.020) and age less than 13 years (OR = 8.54, P = 0.014). During the second observation period, when 20 (22%) children started antimicrobial treatment, the probability of starting treatment was increased in children with neutropenia (OR = 4.25, P = 0.007). There was no statistically significant association between starting treatment for infection and school attendance. CONCLUSIONS In this study, children attending school while undergoing cancer treatment did not run a higher risk of starting antimicrobial treatment than children absent from school. However, there is a need for further studies evaluating risk of infections in children with ongoing cancer treatment.
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Affiliation(s)
- Margareta af Sandeberg
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.
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21
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Cecinati V, Principi N, Brescia L, Esposito S. Antibiotic prophylaxis in children with cancer or who have undergone hematopoietic cell transplantation. Eur J Clin Microbiol Infect Dis 2013; 33:1-6. [PMID: 23884866 DOI: 10.1007/s10096-013-1932-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 07/10/2013] [Indexed: 11/25/2022]
Abstract
Bacterial infections are common in children with cancer and can lead to life-threatening complications. Infections in these patients mainly occur during neutropenic periods, and may be caused by Gram-positive or Gram-negative bacteria. The patients at highest risk of serious infections include those with acute lymphoblastic leukemia (ALL) or acute myeloid leukemia (AML), and those undergoing myeloablative hematopoietic cell transplantation (HCT). This is a review with the main aim of making a critical appraisal of the literature, and summarising what is currently known and can be recommended. The most significant studies support the use of floroquinolones (mainly ciprofloxacin) as the most rational approach to treat pediatric patients with probably long-lasting neutropenia, although trimetoprim-sulphametoxazole and amoxicillin/clavulanate may theoretically be valid alternatives. No prophylaxis seems to be needed for children with cancer without severe neutropenia. However, a global evaluation of the studies of antibiotic prophylaxis in children with cancer indicates that there are not enough data to prepare definite guidelines for its use or avoidance in pediatric oncology, and so further studies are needed. It is not only important to define the best antibiotic regimens for the children in whom such prophylaxis is useful, but also to identify precisely those who do not need it. This would avoid the antibiotic misuse that probably occurs at the moment because many low-risk children with cancer are treated. As prophylaxis against infections requires long-term adherence to an antibiotic regimen, the attitudes and beliefs of stakeholders need to be fully considered.
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Affiliation(s)
- V Cecinati
- Division of Pediatric Hematology and Oncology, Department of Hematology, Santo Spirito Hospital, Pescara, Italy
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22
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Ammann RA, Bodmer N, Simon A, Agyeman P, Leibundgut K, Schlapbach LJ, Niggli FK. Serum Concentrations of Mannan-Binding Lectin (MBL) and MBL-Associated Serine Protease-2 and the Risk of Adverse Events in Pediatric Patients With Cancer and Fever in Neutropenia. J Pediatric Infect Dis Soc 2013; 2:155-61. [PMID: 26619462 DOI: 10.1093/jpids/pit005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 01/01/2013] [Indexed: 11/14/2022]
Abstract
BACKGROUND It is unknown whether serum concentrations of mannan-binding lectin (MBL) and MBL-associated serine protease-2 (MASP-2) influence the risk of adverse events (AEs) in children with cancer presenting with fever in neutropenia (FN). METHODS Pediatric patients with cancer presenting with FN after non-myeloablative chemotherapy were observed in a prospective multicenter study. Mannan-binding lectin and MASP-2 were measured using commercially available enzyme-linked immunosorbent assay in serum taken at cancer diagnosis. Multiple FN episodes per patient were allowed. Associations of MBL and MASP-2 with AE in general, with bacteremia, and with serious medical complications (SMC) during FN were analyzed using mixed logistic regression. RESULTS Of 278 FN episodes, AE was reported in 84 (30%), bacteremia was reported in 42 (15%), and SMC was reported in 16 (5.8%). Median MBL was 2152 ng/mL (range, 7-10 060). It was very low (<100) in 11 (9%) patients, low (100-999) in 36 (29%) patients, and normal (≥1000) in 79 (63%) patients. Median MASP-2 was 410 ng/mL (range, 68-2771). It was low (<200) in 18 (14%) patients and normal in the remaining 108 (86%) patients. Mannan-binding lectin and MASP-2 were not significantly associated with AE or bacteremia. Normal versus low MBL was independently associated with a significantly higher risk of SMC (multivariate odds ratio, 12.8; 95% confidence interval, 1.01-163; P = .050). CONCLUSIONS Mannan-binding lectin and MASP-2 serum concentrations were not found to predict the risk to develop AEs or bacteremia during FN. Normal MBL was associated with an increased risk of SMC during FN. This finding, in line with earlier studies, does not support the concept of MBL supplementation in MBL-deficient children with cancer presenting with FN.
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Affiliation(s)
| | | | - Arne Simon
- Department of Pediatrics, University of Bonn, and Pediatric Oncology, Saarland University Hospital, Homburg, Germany
| | - Philipp Agyeman
- Department of Pediatrics and Institute for Infectious Diseases, University of Bern, and
| | | | - Luregn J Schlapbach
- Department of Pediatrics and Pediatric Critical Care Research Group, Pediatric Intensive Care Unit, Mater Children's Hospital, Brisbane, Australia
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Binz P, Bodmer N, Leibundgut K, Teuffel O, Niggli FK, Ammann RA. Different fever definitions and the rate of fever and neutropenia diagnosed in children with cancer: a retrospective two-center cohort study. Pediatr Blood Cancer 2013. [PMID: 23193083 DOI: 10.1002/pbc.24380] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The definition of fever, and thus fever and neutropenia (FN), varies between different pediatric oncology centers. Higher temperature limit should reduce FN rates, but may increase rates of FN with complications by delaying therapy. This study determined if different fever definitions are associated with different FN rates. PROCEDURE Two pediatric oncology centers had used three fever definitions in 2004-2011: ear temperature ≥38.5 °C persisting ≥2 hours (low definition); axillary temperature ≥38.5 °C ≥ 2 hours or ≥39.0 °C once (middle); and ear temperature ≥39.0 °C once (high). Clinical information was retrospectively extracted from charts. FN rates were compared using mixed Poisson regression. RESULTS In 521 pediatric patients with cancer, 783 FN were recorded during 6,009 months cumulative chemotherapy exposure time (501 years; rate, 0.13/month [95% CI, 0.12-0.14]), 124 of them with bacteremia (16%; 0.021/month [0.017-0.025]). In univariate analysis, the high versus low fever definition was associated with a lower FN rate (0.10/month [0.08-0.11] vs. 0.15/month [0.13-0.16]; rate ratio, 0.66 [0.45-0.97]; P = 0.036), the middle definition was intermediate (0.13/month [0.11-0.15]). This difference was not confirmed in multivariate analysis (rate ratio, 0.94 [0.67-1.33]; P = 0.74). The high versus low definition was not associated with an increased rate of FN with bacteremia (multivariate rate ratio, 1.39 [0.53-3.62]; P = 0.50). CONCLUSION A higher fever definition was not associated with a lower FN rate, nor with an increased rate of FN with bacteremia. These may be false negative findings due to methodological limitations. These questions, with their potential impact on health-related quality of life, and on costs, need to be assessed in prospective studies.
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Affiliation(s)
- Patrizia Binz
- Department of Pediatrics, University of Bern, Bern, Switzerland
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Bagnasco F, Haupt R, Fontana V, Valsecchi MG, Rebora P, Caviglia I, Caruso S, Castagnola E. Risk of repeated febrile episodes during chemotherapy-induced granulocytopenia in children with cancer: a prospective single center study. J Chemother 2012; 24:155-60. [PMID: 22759760 DOI: 10.1179/1973947812y.0000000002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Febrile neutropenia (FN) is a possible complication of antineoplastic chemotherapy. Aim of the study was to estimate the risk of developing fever at the beginning of any neutropenic period based on the previous history of FN. PROCEDURE The conditional frailty model was used to estimate the risk of developing fever during neutropenia separately for children with acute leukaemia/non-Hodgkin lymphoma (AL/NHL), or solid tumour (ST). The total number of previous FN episodes (PFNE), age, gender, type of tumour, calendar year of granulocytopenic period, phase of treatment, and granulocyte count were included in the model. RESULTS A total of 901 granulocytopenic periods was observed in 223 children: 306 in 66 AL/NHL and 595 in 157 ST. Fever developed in 328 cases: 125 in 53 AL/NHL and 203 in 92 ST. The PFNE variable was not significantly associated to the risk of fever [hazard ratio (HR) of 0.87, 95% confidence interval (CI) of 0.62-1.22 in children with AL/NHL, and HR of 0.98, 95% CI of 0.70-1.37 in those with ST]. The hazard of FN was significantly affected by the phase of treatment in AL/NHL (P<0.01), and by the level of neutropenia at onset in ST (P<0.01). CONCLUSIONS Previous history of FN does not increase the risk of further febrile episodes in any new subsequent granulocytopenic period. The aggressiveness of chemotherapy and the level of neutropenia at onset are the most important risk factors in children with AL/NHL and with ST respectively.
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Affiliation(s)
- Francesca Bagnasco
- Epidemiology and Biostatistics Section, Scientific Directorate, G. Gaslini Children's Hospital, Genoa, Italy
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Lehrnbecher T. [Infectious complications in acute lymphoblastic leukemia: Individually tailored prevention and treatment]. ACTA ACUST UNITED AC 2012; 41:228-33. [PMID: 22844670 DOI: 10.1002/pauz.201200472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Thomas Lehrnbecher
- Pädiatrische Hämatologie, Onkologie und Hämostaseologie, Zentrum für Kinder- und Jugendmedizin – Klinik III, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Frankfurt, Deutschland.
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Lüthi F, Leibundgut K, Niggli FK, Nadal D, Aebi C, Bodmer N, Ammann RA. Serious medical complications in children with cancer and fever in chemotherapy-induced neutropenia: results of the prospective multicenter SPOG 2003 FN study. Pediatr Blood Cancer 2012; 59:90-5. [PMID: 21837771 DOI: 10.1002/pbc.23277] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 06/21/2011] [Indexed: 01/09/2023]
Abstract
BACKGROUND Fever and chemotherapy-induced neutropenia (FN) is the most frequent potentially lethal complication of therapy in children with cancer. This study aimed to describe serious medical complications (SMC) in children with FN regarding incidence, clinical spectrum, and associated characteristics. PROCEDURE Pediatric patients presenting with FN induced by non-myeloablative chemotherapy were observed in a prospective multicenter study. SMC was defined as potentially life-threatening complication (PLTC), transfer to the pediatric intensive care unit (PICU), or death. RESULTS A total of 443 FN episodes were reported from 8 centers. Of these, 411 episodes were reported from 4 centers recruiting consecutively and without bias regarding the risk of complications. They were used for calculation of proportions. An SMC was reported in 23 episodes [5.6%; 95% confidence interval (CI): 3.7-8.1], usually defined by more than one criterion. These were PLTC in 13 episodes, PICU in 22, and death in 3 (mortality, 0.7%; 95% CI: 0.2-2.1). Both a delayed onset of SMC (14 of 23 episodes, 61%) and a biphasic clinical course (11 of 23, 48%) were frequently observed. In a multivariate logistic regression analysis, 4 characteristics were significantly and independently associated with the risk of SMC: diagnosis of acute myeloid leukemia, interval since chemotherapy ≤7 days, severely reduced general condition, and hemoglobin ≥9.0 g/dl at presentation. CONCLUSIONS In children with FN, SMC were rare, and mortality was very low. Those with SMC often had a delayed onset and biphasic clinical course with secondary deterioration.
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Affiliation(s)
- Fabienne Lüthi
- Department of Pediatrics, University of Bern, Bern, Switzerland
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The use of antimicrobial agents in children with fever during chemotherapy-induced neutropenia: the importance of risk stratification. Pediatr Infect Dis J 2011; 30:887-90. [PMID: 21915020 DOI: 10.1097/inf.0b013e3182311343] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Children with fever and chemotherapy-induced or cancer-associated neutropenia should be assessed with complete history and physical examinations, undergo appropriate diagnostic studies, and promptly receive broad-spectrum empirical antimicrobial therapy. Assessment of risk for severe infection is crucial in determining the appropriate antimicrobial, route, venue, and duration of empirical antimicrobial therapy and need for prophylactic antimicrobial agents.
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Hakim H, Gaur AH. Initial Management of Fever and Neutropenia in a Child With Cancer—The Past, the Present, and the Future. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2011. [DOI: 10.1016/j.cpem.2011.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Klastersky J, Awada A, Paesmans M, Aoun M. Febrile neutropenia: A critical review of the initial management. Crit Rev Oncol Hematol 2011; 78:185-94. [DOI: 10.1016/j.critrevonc.2010.03.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 03/10/2010] [Accepted: 03/24/2010] [Indexed: 11/28/2022] Open
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Demir HA, Kutluk T, Ceyhan M, Yağcı-Küpeli B, Akyüz C, Cengiz B, Varan A, Kara A, Yalçın B, Seçmeer G, Büyükpamukçu M. Comparison of sulbactam-cefoperazone with carbapenems as empirical monotherapy for febrile neutropenic children with lymphoma and solid tumors. Pediatr Hematol Oncol 2011; 28:299-310. [PMID: 21413829 DOI: 10.3109/08880018.2011.552937] [Citation(s) in RCA: 10] [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
Febrile neutropenia (FEN) is a leading complication of intensive chemotherapy. With this prospective randomized study, the authors aimed to compare the effectiveness of sulbactam-cefoperazone (SC) versus carbapenems, as empirical monotherapy in febrile neutropenic children with lymphoma and solid tumors. Febrile neutropenic children (age ≤16 years) hospitalized at the authors' center for lymphomas or solid tumors between March 2007 and June 2009 were included in the study. Patients randomly received SC or carbapenem. Patients were reevaluated at 72 hours and in case of persistent fever, an aminoglycoside and/or a glycopeptide was added to the antibiotic treatment. When a resistant pathogen was isolated, the antibiotic therapy was modified. Treatment responses was defined as success without modification, overall success, or failure. Two hundred and eight episodes were documented in 128 patients (F/M: 56/72), with a median age of 7 years (0.5-17.4 years). Absolute neutrophil count and duration of neutropenia in patients treated with SC and carbapenems were 133/mm(3) (0-500) and 113/mm(3) (0-500), and 4 days (1-21) and 5 days (2-20), respectively. In the SC and carbapenem groups, 82 (78.8%) and 84 episodes (80.7%) improved with treatment, whereas 21 (20.2%) and 19 (18.3%) episodes required treatment modification respectively. One patient from each treatment group died according to febrile neutropenia. The overall success rates were 99% in both groups (P = .94). Empiric SC therapy was found to be as effective as carbapenem monotherapy in pediatric febrile neutropenic patients with lymphoma and solid tumors.
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Affiliation(s)
- Hacı Ahmet Demir
- Department of Pediatric Oncology, Institute of Oncology, Hacettepe University, Ankara, Turkey
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Saavedra-Lozano J, Garrido C, Catalán P, González F. [Children with cancer and respiratory viral infection: epidemiology, diagnosis and treatment options]. Enferm Infecc Microbiol Clin 2010; 29:40-51. [PMID: 21183254 PMCID: PMC7103288 DOI: 10.1016/j.eimc.2010.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 04/26/2010] [Accepted: 04/30/2010] [Indexed: 11/26/2022]
Abstract
Community-adquired respiratory viral infection is the most common cause of febrile infection in children, and an important cause of infection to consider in children with cancer. Nevertheless, there are few well-designed, controlled studies in this population, which makes it difficult to understand the importance, behaviour and management of these viruses in immunocompromised children. New diagnostic techniques in PCR-based microbiology, could provide many opportunities for early diagnosis, preventing the spread of the virus and to implement the correct therapy. It is important to design appropriate prospective studies to assess these types of infections in children with cancer. In this review we analyse the main studies published in the literature, evaluating the epidemiology, diagnosis and management of children with cancer and respiratory viral infection.
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Affiliation(s)
- Jesús Saavedra-Lozano
- Servicio de Pediatría, Hospital General Universitario Gregorio Marañón, Madrid, España.
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Abstract
PURPOSE OF REVIEW To provide an update on the rational approach of febrile neutropenia in children with cancer and discuss future research aspects in the field. RECENT FINDINGS Clinical and laboratory variables and new biomarkers associated with an increased risk for a severe outcome including invasive bacterial infection (IBI), sepsis, and mortality have been identified for children with cancer and febrile neutropenia. These variables and biomarkers are currently being used for an early risk assessment in order to identify children at low or high risk for IBI or at high risk for sepsis and death. Early identification of children with a differential risk has allowed the implementation of selective treatment regimens. More recently, host genetic differences have been associated with a differential risk for IBI. The individual gene profile based on selected polymorphisms could further fine-tune the early risk assessment allowing tailor-made management strategies. SUMMARY In the last decades, efforts have focused on the stratification of the heterogeneous group of children with cancer and febrile neutropenia according to their risk for developing an IBI. This effort has allowed a less aggressive treatment strategy for children at low risk, including early hospital discharge and use of intravenous and oral antimicrobials at home. More recently, advances have been made in the early identification of children in the other spectrum of infection, those at high risk for sepsis and mortality, with the aim of rapid implementation of aggressive therapy.
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Abstract
BACKGROUND To identify predictors for 2 risk measures-"proven invasive bacterial infection or culture-negative sepsis (IBD)" and "clinical complications (CC)"-in pediatric cancer patients with fever and neutropenia (FN). METHODS Records of 390 patients with FN hospitalized over 2 years were reviewed. For the 332 who met inclusion criteria, one FN episode was randomly selected. Independent predictors at presentation were analyzed using multiple regression models. Optimal cut-off risk prediction scores were determined. These models were validated by bootstrap analysis. RESULTS Patients' median age was 6.0 years; 66% had an underlying diagnosis of leukemia. Independent predictors of IBD (n = 56) were absolute neutrophil count <100, temperature at presentation > or =39.0 degrees C, "sick" clinical appearance, and underlying diagnosis of acute myeloid leukemia. A total weighted score <24 reliably identified patients at low risk for IBD. Independent predictors of CC (n = 47) were relapse of malignancy, non-white race, "sick" clinical appearance, and underlying diagnosis of acute myeloid leukemia. A total weighted score <19 predicted patients at low risk for CC. Of those misclassified as low risk, 11 of 12 with IBD and 3 of 9 with CC had the outcome within 24 hours of presentation. Of the remaining patients classified as low-risk for IBD and CC, 99.5% and 97.1%, respectively, remained outcome-free after 24 hours of observation. CONCLUSIONS This study identifies predictors of infection/complications in pediatric patients with FN, establishes clinical cut-off scores and highlights the importance of the initial clinical impression and 24 hours of observation. These prediction models warrant prospective validation.
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Abstract
PURPOSE OF REVIEW The present review updates treatment of neutropenia from articles published from January 2008 through April 2009. RECENT FINDINGS Chemotherapy-induced neutropenia occurs most commonly in the first cycle of treatment. Older patients, patients with multiple comorbidities, and those receiving more myelotoxic drugs are prone to develop neutropenia and its complications. Current guidelines recommend the prophylactic use of the myeloid growth factors for the first cycle of chemotherapy for patients with more than a 20% risk of febrile neutropenia. Meta analysis from randomized trials shows that granulocyte colony-stimulating factor prophylaxis is associated with patients receiving more intensive chemotherapy, having better survival, but also having a higher risk of secondary acute myeloid leukemia. Antibiotics are standard treatment of febrile neutropenia and are increasingly used for prophylaxis in 'low-risk' patients. SUMMARY The myeloid growth factor granulocyte colony-stimulating factor has radically changed our approach to the prevention of febrile neutropenia. Antibiotics remain the mainstay of treatment of febrile neutropenia.
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Schlapbach LJ, Aebi C, Hansen AG, Hirt A, Jensenius JC, Ammann RA. H-ficolin serum concentration and susceptibility to fever and neutropenia in paediatric cancer patients. Clin Exp Immunol 2009; 157:83-9. [PMID: 19659773 DOI: 10.1111/j.1365-2249.2009.03957.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
H-ficolin (Hakata antigen, ficolin-3) activates the lectin pathway of complement similar to mannose-binding lectin. However, its impact on susceptibility to infection is currently unknown. This study investigated whether the serum concentration of H-ficolin at diagnosis is associated with fever and neutropenia (FN) in paediatric cancer patients. H-ficolin was measured by time-resolved immunofluorometric assay in serum taken at cancer diagnosis from 94 children treated with chemotherapy. The association of FN episodes with H-ficolin serum concentration was analysed by multivariate Poisson regression. Median concentration of H-ficolin in serum was 26 mg/l (range 6-83). Seven (7%) children had low H-ficolin (< 14 mg/l). During a cumulative chemotherapy exposure time of 82 years, 177 FN episodes were recorded, 35 (20%) of them with bacteraemia. Children with low H-ficolin had a significantly increased risk to develop FN [relative risk (RR) 2.24; 95% confidence interval (CI) 1.38-3.65; P = 0.004], resulting in prolonged duration of hospitalization and of intravenous anti-microbial therapy. Bacteraemia occurred more frequently in children with low H-ficolin (RR 2.82; CI 1.02-7.76; P = 0.045). In conclusion, low concentration of H-ficolin was associated with an increased risk of FN, particularly FN with bacteraemia, in children treated with chemotherapy for cancer. Low H-ficolin thus represents a novel risk factor for chemotherapy-related infections.
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Affiliation(s)
- L J Schlapbach
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Bern, Bern, Switzerland.
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Randomized controlled trial comparing oral amoxicillin-clavulanate and ofloxacin with intravenous ceftriaxone and amikacin as outpatient therapy in pediatric low-risk febrile neutropenia. J Pediatr Hematol Oncol 2009; 31:635-41. [PMID: 19684522 DOI: 10.1097/mph.0b013e3181acd8cd] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Outpatient oral therapy is infrequently used in pediatric low-risk febrile neutropenia (LRFN) as there is insufficient data regarding its equivalence as compared with parenteral therapy. METHODS This is a single institutional, randomized control trial in pediatric LRFN aged 2 to 15 years, in which 123 episodes in 88 patients were randomized to outpatient oral ofloxacin 7.5 mg/kg 12 hourly and amoxycillin-clavulanate 12.5 mg/kg 8 hourly or outpatient intravenous (IV) ceftriaxone 75 mg/kg and amikacin 15 mg/kg once daily after blood cultures. RESULTS Out of 119 evaluable episodes, one-third were leukemia patients in maintenance and rest were solid tumors. Success was achieved in 55/61 (90.16%) and 54/58 (93.1%) in oral and IV arms, respectively, (P=0.56). There were 3 hospitalizations but no mortality. Median days to resolution of fever, absolute neutrophil count >500/mm(3) and antibiotic use were 3, 5, and 6 days in both arms. There were 5 blood culture isolates (3 gram-positive and 2 gram-negative bacteria). Failure of outpatient therapy was associated with perianal infections, bacteremia, febrile neutropenia onset before day 9 of chemotherapy in solid tumors and Vincristine, actinomycin-D, and cyclophosphamide chemotherapy for rhabdomyosarcoma. All gram-positive isolates were successes, whereas both gram-negative isolates were failures. Diarrhea in IV arm and Vincristine, actinomycin-D, and cyclophosphamide chemotherapy in the oral arm predicted failure in subgroup analysis. CONCLUSIONS Outpatient therapy is efficacious and safe in pediatric LRFN. There was no difference in outcome in oral versus IV outpatient therapy. Amoxycillin-clavulanate and ofloxacin may be the oral regimen of choice.
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A Case of Neonatal Neutropenia Due to Anti-Fc Gamma Receptor IIIb Isoantibodies Treated with Recombinant Human Granulocyte Colony Stimulating Factor. Case Rep Med 2009; 2009:717545. [PMID: 19730745 PMCID: PMC2734935 DOI: 10.1155/2009/717545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 07/18/2009] [Indexed: 11/18/2022] Open
Abstract
Alloimmunization to granulocyte-specific antigens can occur during pregnancy. Maternal antibodies of IgG class can cross the placenta to result in alloimmune neonatal neutropenia. Antibodies to human neutrophil antigens anti-HNA-1a, HNA-1b, and HNA-2a have been most commonly reported to cause alloimmune neonatal neutropenia. Isoantibodies to Fc gamma RIIIb (CD16) if mother is a HNA-null phenotype are rarely involved in neonatal neutropenia. We report on a case of severe neutropenia (440 neutrophils/μL) due to anti-Fc gamma RIIIb (CD16) isoimmunization. On day 14 severe omphalitis developed, which was treated for 7 days by an antibiotic (ceftriaxone in a dose of 80 mg/kg/d) according to umbilical swab finding. Omphalitis persisted for 10 days in spite of antibiotic therapy and only resolved upon the introduction of rhG-CSF therapy. Therapy with rh-GCSF proved efficient and led to neutrophil count increase to 1970/μL and cure of omphalitis. However, therapeutic effect on granulocyte count was of transient nature, as granulocyte count fell to 760 n/μL on day 4 of therapy discontinuation. Neutropenia persisted for 2 months. The newborn was discharged from the hospital on day 26 with normal clinical status with clinical and laboratory control examinations at 2-week intervals. No additional infections were observed during the course of neutropenia.
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