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Wu H, Li M, Shou C, Shi F, Song X, Hu Q, Wang Y, Chen Y, Tong X. Pathogenic spectrum and drug resistance of bloodstream infection in patients with acute myeloid leukaemia: a single centre retrospective study. Front Cell Infect Microbiol 2024; 14:1390053. [PMID: 38912203 PMCID: PMC11190328 DOI: 10.3389/fcimb.2024.1390053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/10/2024] [Indexed: 06/25/2024] Open
Abstract
Background Bloodstream infection (BSI) represent a prevalent complication in haematological malignancies (HMs). Typically, Patients with BSI usually undergo empirical treatment pending pathogen identification. The timely and effective management of BSIs significantly influences patient prognosis. However, pathogen distribution in BSIs exhibits regional variation. In this study, we investigated the clinical characteristics, pathogen spectrum, drug resistance, risk factors of short-term prognosis and long-term prognostic factors of acute myeloid leukemia (AML) patients with BSI at Zhejiang Provincal People's Hospital. Methods From 2019 to 2021, a total of 56 AML patients with BSI were treated in the Department of Haematology at Zhejiang Province People's Hospital. Data regarding pathogen spectrum and drug resistance were collected for analysis. The patients were stratified into non-survivor cohort and survivor cohort within 30 days after BSI, and the predictors of 30-days mortality were identified through both univariate and multivariate Logistic regression analyses. Furthermore, Kaplan-Meier survival analysis and Cox regression analysis were employed to ascertain the risk factors associated with poor prognosis in AML patients complicated by BSI. Results A total of 70 strains of pathogenic bacteria were isolated from 56 AML patients with BSI. Gram-negative bacteria constituted the predominant pathogens (71.4%), with Klebsiella pneumoniae being the most prevalent (22.9%). Gram-positive bacteria and fungi accounted for 22.9% and 5.7%, respectively. Univariate and multivariate analyses revealed significant differences in total protein, albumin levels, and the presence of septic shock between the non-survivor cohort and the survior cohort 30 days post-BSI. COX regression analysis showed that agranulocytosis duration exceeding 20 days (HR:3.854; 95% CI: 1.451-10.242) and septic shock (HR:3.788; 95% CI: 1.729-8.299) were independent risk factors for poor prognosis in AML patients complicated by BSI. Notably, the mortality rate within 30 days after Stenotrophomonas maltophilia infection was up to 71.4%. Conclusions In this study, Gram-negative bacteria, predominantly Klebsiella pneumoniae, constituted the primary pathogens among AML patients with BSIs. Serum albumin levels and the presence of septic shock emerged as independent risk factors for mortality within 30 days among AML patients with BSI. In terms of long-term prognosis, extended agranulocytosis duration exceeding 20 days and septic shock were associated with elevated mortality rates in AML patients with BSI. Additionally, in our centre, Stenotrophomonas maltophilia infection was found to be associated with a poor prognosis. Early intervention for Stenotrophomonas maltophilia infection in our centre could potentially improve patient outcomes.
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Affiliation(s)
- Han Wu
- Graduate School of Clinical Medicine, Jinzhou Medical University, Jinzhou, Liaoning, China
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Manning Li
- Graduate School of Clinical Medicine, Jinzhou Medical University, Jinzhou, Liaoning, China
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Chunyi Shou
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Fangfang Shi
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiaolu Song
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Qingfeng Hu
- Department of Clinical Laboratory, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Ying Wang
- Department of Central Laboratory, Affiliated Hangzhou First People’s Hospital, Xihu University, Hangzhou, Zhejiang, China
| | - Yirui Chen
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiangmin Tong
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Xihu University, Hangzhou, Zhejiang, China
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Li Q, Zhou X, Yang R, Shen X, Li G, Zhang C, Li P, Li S, Xie J, Yang Y. Carbapenem-resistant Gram-negative bacteria (CR-GNB) in ICUs: resistance genes, therapeutics, and prevention - a comprehensive review. Front Public Health 2024; 12:1376513. [PMID: 38601497 PMCID: PMC11004409 DOI: 10.3389/fpubh.2024.1376513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/20/2024] [Indexed: 04/12/2024] Open
Abstract
Intensive care units (ICUs) are specialized environments dedicated to the management of critically ill patients, who are particularly susceptible to drug-resistant bacteria. Among these, carbapenem-resistant Gram-negative bacteria (CR-GNB) pose a significant threat endangering the lives of ICU patients. Carbapenemase production is a key resistance mechanism in CR-GNB, with the transfer of resistance genes contributing to the extensive emergence of antimicrobial resistance (AMR). CR-GNB infections are widespread in ICUs, highlighting an urgent need for prevention and control measures to reduce mortality rates associated with CR-GNB transmission or infection. This review provides an overview of key aspects surrounding CR-GNB within ICUs. We examine the mechanisms of bacterial drug resistance, the resistance genes that frequently occur with CR-GNB infections in ICU, and the therapeutic options against carbapenemase genotypes. Additionally, we highlight crucial preventive measures to impede the transmission and spread of CR-GNB within ICUs, along with reviewing the advances made in the field of clinical predictive modeling research, which hold excellent potential for practical application.
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Affiliation(s)
- Qi Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoshi Zhou
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Rou Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoyan Shen
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, Chengdu Qingbaijiang District People's Hospital, Chengdu, China
| | - Guolin Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Changji Zhang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Pengfei Li
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Shiran Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jingxian Xie
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Zhao Z, Patel PA, Slatnick L, Sitthi-Amorn A, Bielamowicz KJ, Nunez FA, Walsh AM, Hess J, Rossoff J, Elgarten C, Myers R, Saab R, Basbous M, Mccormick M, Aftandilian C, Richards R, Nessle CN, Tribble AC, Sheth Bhutada JK, Coven SL, Runco D, Wilkes J, Gurunathan A, Guinipero T, Belsky JA, Lee K, Wong V, Malhotra M, Armstrong A, Jerkins LP, Cross SJ, Fisher L, Stein MT, Wu NL, Yi T, Orgel E, Haeusler GM, Wolf J, Demedis JM, Miller TP, Esbenshade AJ. Prospective External Validation of the Esbenshade Vanderbilt Models Accurately Predicts Bloodstream Infection Risk in Febrile Non-Neutropenic Children With Cancer. J Clin Oncol 2024; 42:832-841. [PMID: 38060973 PMCID: PMC10906655 DOI: 10.1200/jco.23.01814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/11/2023] [Accepted: 10/17/2023] [Indexed: 02/29/2024] Open
Abstract
PURPOSE The optimal management of fever without severe neutropenia (absolute neutrophil count [ANC] ≥500/µL) in pediatric patients with cancer is undefined. The previously proposed Esbenshade Vanderbilt (EsVan) models accurately predict bacterial bloodstream infections (BSIs) in this population and provide risk stratification to aid management, but have lacked prospective external validation. MATERIALS AND METHODS Episodes of fever with a central venous catheter and ANC ≥500/µL occurring in pediatric patients with cancer were prospectively collected from 18 academic medical centers. Variables included in the EsVan models and 7-day clinical outcomes were collected. Five versions of the EsVan models were applied to the data with calculation of C-statistics for both overall BSI rate and high-risk organism BSI (gram-negative and Staphylococcus aureus BSI), as well as model calibration. RESULTS In 2,565 evaluable episodes, the BSI rate was 4.7% (N = 120). Complications for the whole cohort were rare, with 1.1% (N = 27) needing intensive care unit (ICU) care by 7 days, and the all-cause mortality rate was 0.2% (N = 5), with only one potential infection-related death. C-statistics ranged from 0.775 to 0.789 for predicting overall BSI, with improved accuracy in predicting high-risk organism BSI (C-statistic 0.800-0.819). Initial empiric antibiotics were withheld in 14.9% of episodes, with no deaths or ICU admissions attributable to not receiving empiric antibiotics. CONCLUSION The EsVan models, especially EsVan2b, perform very well prospectively across multiple academic medical centers and accurately stratify risk of BSI in episodes of non-neutropenic fever in pediatric patients with cancer. Implementation of routine screening with risk-stratified management for non-neutropenic fever in pediatric patients with cancer could safely reduce unnecessary antibiotic use.
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Affiliation(s)
- Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center and the Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Pratik A. Patel
- Pediatric Hematology/Oncology, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Leonora Slatnick
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, University of Colorado Anschutz Medical Center, Children's Hospital Colorado, Aurora, CO
| | - Anna Sitthi-Amorn
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Kevin J. Bielamowicz
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR
| | - Farranaz A. Nunez
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR
| | | | | | - Jenna Rossoff
- Department of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Caitlin Elgarten
- Children's Hospital of Philadelphia, Division of Oncology, Philadelphia, PA
| | - Regina Myers
- Children's Hospital of Philadelphia, Division of Oncology, Philadelphia, PA
| | - Raya Saab
- Children's Cancer Institute, Department of Pediatrics, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maya Basbous
- Children's Cancer Institute, Department of Pediatrics, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Catherine Aftandilian
- Department of Pediatric Hematology, Oncology, Stem Cell Transplant and Regenerative Medicine Stanford University, Palo Alto, CA
| | - Rebecca Richards
- Department of Pediatric Hematology, Oncology, Stem Cell Transplant and Regenerative Medicine Stanford University, Palo Alto, CA
| | - C. Nathan Nessle
- Department of Pediatrics, Division of Pediatric Hematology Oncology, University of Michigan, Ann Arbor, MI
| | - Alison C. Tribble
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Michigan, Ann Arbor, MI
| | - Jessica K. Sheth Bhutada
- Cancer and Blood Disease Institute, Children's Hospital of Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Scott L. Coven
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Department of Pediatrics, Division of Pediatric Hematology/Oncology, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN
| | - Daniel Runco
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Department of Pediatrics, Division of Pediatric Hematology/Oncology, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN
| | - Jennifer Wilkes
- Division of Pediatric Hematology and Oncology and Bone Marrow Transplant, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Arun Gurunathan
- Division of Pediatric Hematology and Oncology and Bone Marrow Transplant, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Terri Guinipero
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer A. Belsky
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Department of Pediatrics, Division of Pediatric Hematology/Oncology, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN
| | - Karen Lee
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, CA
| | - Victor Wong
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, CA
| | - Megha Malhotra
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Washington University in St Louis School of Medicine, St Louis, MO
| | - Amy Armstrong
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Washington University in St Louis School of Medicine, St Louis, MO
| | - Lauren P. Jerkins
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Shane J. Cross
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN
| | - Lyndsay Fisher
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR
| | - Madison T. Stein
- Children's Hospital of Philadelphia, Division of Oncology, Philadelphia, PA
| | - Natalie L. Wu
- Division of Pediatric Hematology and Oncology and Bone Marrow Transplant, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Troy Yi
- Division of Pediatric Hematology and Oncology and Bone Marrow Transplant, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Etan Orgel
- Cancer and Blood Disease Institute, Children's Hospital of Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Joshua Wolf
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN
| | - Jenna M. Demedis
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, University of Colorado Anschutz Medical Center, Children's Hospital Colorado, Aurora, CO
| | - Tamara P. Miller
- Pediatric Hematology/Oncology, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Adam J. Esbenshade
- Department of Pediatrics, Vanderbilt University Medical Center and the Monroe Carell Jr. Children's Hospital at Vanderbilt and the Vanderbilt-Ingram Cancer Center, Nashville, TN
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Prather CS, Wood JB, Mueller EL, Christenson JC, Alali M. The Yield, Safety, and Cost-effectiveness of Decreasing Repeat Blood Cultures Beyond 48 Hours in a Pediatric Hematology-Oncology Unit. J Pediatr Hematol Oncol 2023; 45:409-415. [PMID: 37526364 DOI: 10.1097/mph.0000000000002711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 06/13/2023] [Indexed: 08/02/2023]
Abstract
Clear recommendations are needed on when repeat blood cultures (BCxs) in hospitalized children with cancer should be obtained. We reviewed all BCx obtained on the Hematology-Oncology Unit at Riley Hospital for Children, regardless of reason for patient admission or neutropenia status, between January 2015 and February 2021. Patients with positive BCx within 48 hours of initial cultures, history of stem cell transplant, or admitted to the intensive care unit were excluded. Medical records of patients with new positive BCx drawn >48 hours after initial BCx were reviewed. Seven (1.2%) hospitalization episodes grew new pathogens, or commensals treated as pathogens, on cultures beyond 48 hours. All patients with new, true pathogens were hemodynamically unstable or had recurrent fever when the new positive BCx was obtained. Twenty-three (4.0%) hospitalization episodes had contaminant cultures beyond 48 hours, with 74 (5.4%) of 1362 BCx collected beyond 48 hours being contaminated, resulting in an additional cost of $210,519 from increased length of stay. In conclusion, repeat BCx beyond 48 hours in pediatric hematology-oncology patients with negative initial cultures are low yield and costly. Repeat BCx can be safely and cost-effectively ceased after 48 hours of negative cultures in hemodynamically and clinically stable patients.
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Affiliation(s)
| | - James B Wood
- Ryan White Center for Pediatric Infectious Diseases and Global Health
- Center for Pediatric and Adolescent Comparative Effectiveness Research
| | - Emily L Mueller
- Center for Pediatric and Adolescent Comparative Effectiveness Research
- Section of Pediatric Hematology-Oncology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | - Muayad Alali
- Ryan White Center for Pediatric Infectious Diseases and Global Health
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Jackson K, Anderson V, Zhao Z, Kitko CL, Connelly JA, Ho RH, Banerjee R, Dulek DE, Friedman DL, Esbenshade AJ. Applying a risk prediction model for bloodstream infection in a febrile, nonseverely neutropenic cohort of pediatric stem cell transplant patients. Cancer 2023; 129:1591-1601. [PMID: 36828805 DOI: 10.1002/cncr.34703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND The optimal management of febrile stem cell transplant (SCT) patients presenting without severe neutropenia (absolute neutrophil count [ANC] ≥ 500/µL) is unclear. The authors have developed iterative risk prediction models (Esbenshade Vanderbilt [EsVan] models) that reliably predict bloodstream infections (BSIs) in the febrile general pediatric oncology population without severe neutropenia, but SCT-specific data are limited. METHODS All SCTs occurring from May 2005 to November 2019 at a single institution were identified. Episodes of fever with a central venous catheter and ANC values ≥ 500/µL were abstracted. All previous versions of the EsVan model were applied to the SCT data, and c-statistics were generated. The models were additionally applied to each type of transplant (autologous/allogeneic), and a new allogeneic model that further adjusted for metrics of immunosuppression, Esbenshade Vanderbilt Allogeneic SCT Model (EsVanAlloSCT), was developed and internally validated. RESULTS For 429 SCT episodes (221 autologous and 208 allogeneic), the BSI incidence was 19.6% (84 of 429), and it was higher in allogeneic transplant patients (25.5%) than autologous transplant patients (14.0%; p < .01). All versions of the EsVan model performed well for the overall SCT cohort (c-statistics, 0.759-0.795). The EsVan models performed better for the autologous episodes (c-statistics, 0.869-0.881) than the allogeneic SCT episodes (c-statistics, 0.678-0.717). The new allogeneic transplant-specific model, EsVanAlloSCT, which added an adjustment for the extent of immunosuppression, yielded a c-statistic of 0.792 (bootstrap-corrected, 0.750). CONCLUSIONS The EsVan models work exceptionally well when they are applied to autologous SCT, but they work less well for allogeneic SCT. EsVanAlloSCT appears to improve the predictive ability in allogeneic SCT, but it will need additional external validation.
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Affiliation(s)
- Kasey Jackson
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | | | - Zhiguo Zhao
- Department of Statistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carrie L Kitko
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - James A Connelly
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Richard H Ho
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Ritu Banerjee
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Infectious Disease, Nashville, Tennessee, USA
| | - Daniel E Dulek
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Infectious Disease, Nashville, Tennessee, USA
| | - Debra L Friedman
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Adam J Esbenshade
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
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Patel PA, DeGroote NP, Jackson K, Cash T, Castellino SM, Jaggi P, Esbenshade AJ, Miller TP. Infectious events in pediatric patients with acute lymphoblastic leukemia/lymphoma undergoing evaluation for fever without severe neutropenia. Cancer 2022; 128:4129-4138. [PMID: 36238979 PMCID: PMC10311637 DOI: 10.1002/cncr.34476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 07/12/2022] [Accepted: 07/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Infections cause significant treatment-related morbidity during pediatric acute lymphoblastic leukemia/lymphoma (ALL/LLy) therapy. Fevers during periods without severe neutropenia are common, but etiologies are not well-described. This study sought to describe the bloodstream infection (BSI) and non-BSI risk in children undergoing therapy for ALL/LLy. METHODS Demographic and clinical data were abstracted for febrile episodes without severe neutropenia at two children's hospitals. Treatment courses were stratified by intensity. Multivariate logistic regression evaluated characteristics associated with infection. RESULTS There were 1591 febrile episodes experienced by 524 patients. Of these, 536 (34%) episodes had ≥1 infection; BSI occurred in 30 (1.9%) episodes. No BSIs occurred in episodes with a recent procedural sedation or cytarabine exposure. Presence of hypotension, chills/rigors, higher temperature, and infant phenotype were independently associated with BSI (p < .05). Of the 572 non-BSIs, the most common was upper respiratory infection (URI) (n = 381, 67%). Compared to episodes without infection, URI symptoms, higher temperature, absolute neutrophil count 500-999/μl, and evaluation during a low-intensity treatment course were more likely to be associated with a non-BSI (p < .05) and inpatient status was less likely to be associated with a non-BSI (p < .05). CONCLUSIONS The BSI rate in pediatric patients with ALL/LLy and fever without severe neutropenia is low, but one-third of the time, patients have a non-BSI. Future research should test if the need for empiric antibiotics can be tailored based on the associations identified in this study.
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Affiliation(s)
- Pratik A. Patel
- Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
- Division of Pediatric Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Nicholas P. DeGroote
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kasey Jackson
- Division of Pediatric Hematology-Oncology, Monroe Carell Jr Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Thomas Cash
- Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Sharon M. Castellino
- Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Preeti Jaggi
- Division of Pediatric Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Adam J. Esbenshade
- Division of Pediatric Hematology-Oncology, Monroe Carell Jr Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Tamara P. Miller
- Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
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Walker H, Esbenshade AJ, Dale S, Bhatia K, Zhao Z, Babl FE, Conyers R, Haeusler GM. Non-neutropenic fever in children with cancer: Management, outcomes and clinical decision rule validation. Pediatr Blood Cancer 2022; 69:e29931. [PMID: 36031722 DOI: 10.1002/pbc.29931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/18/2022] [Accepted: 07/29/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Fever and infection are an important complication of childhood cancer therapy. Most research and guideline development has focussed on febrile neutropenia, with a paucity directed at non-neutropenic fever (NNF). We describe the clinical presentation, management and outcomes of NNF in children with cancer, and externally validate the Esbenshade Vanderbilt (EsVan) clinical decision rules (CDR) to predict bacteraemia. METHOD Using a prospective database, retrospective data were collected on consecutive NNF episodes (fever ≥38.0°C and absolute neutrophil count >1.0 cells/mm3 ). Sensitivity, specificity and area under the receiver operator characteristic curve (AUC-ROC) of the CDR were compared to derivation study. RESULTS There were 203 NNF episodes occurring in 125 patients. Severe sepsis was uncommon (n = 2, 1%) and bacteraemia occurred in 10 (4.9%, 95% confidence interval [CI]: 2.7%-8.8%) episodes. A confirmed or presumed bacterial infection requiring antibiotics occurred in 31 (15%) patients. Total 202 (99%) episodes received at least one dose of intravenous broad-spectrum antibiotic and 141 (70%) episodes were admitted to hospital. Six (3%) episodes required intensive care unit (ICU)-level care and there were no infection-related deaths. The EsVan 1 rule had an AUC-ROC of 0.67, 80% were identified as low risk, and sensitivity and specificity were 50% and 81.5%, respectively, for a risk threshold of 10%. CONCLUSIONS Serious infection and adverse outcome are uncommon in children with NNF. Many children did not have a bacterial cause of infection identified, but were still treated with broad-spectrum antibiotics and admitted to hospital. National clinical practice guidelines should be developed for this important cohort to enable risk stratification and optimise antibiotic management. Further research is required to determine appropriateness of EsVan CDR in our cohort.
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Affiliation(s)
- Hannah Walker
- The Children's Cancer Centre, The Royal Children's Hospital Parkville, Parkville, Victoria, Australia
| | - Adam J Esbenshade
- Department of Pediatrics, Vanderbilt University Medical Centre, Nashville, Tennessee, USA.,Vanderbilt Ingram Cancer Centre, Nashville, Tennessee, USA
| | - Stephanie Dale
- The Children's Cancer Centre, The Royal Children's Hospital Parkville, Parkville, Victoria, Australia.,The Children's Cancer Centre, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Kanika Bhatia
- The Children's Cancer Centre, The Royal Children's Hospital Parkville, Parkville, Victoria, Australia
| | - Zhiguo Zhao
- Vanderbilt Ingram Cancer Centre, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Franz E Babl
- Emergency Department, The Royal Children's Hospital Parkville, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics and Critical Care, University of Melbourne, Parkville, Victoria, Australia
| | - Rachel Conyers
- The Children's Cancer Centre, The Royal Children's Hospital Parkville, Parkville, Victoria, Australia.,Department of Paediatrics and Critical Care, University of Melbourne, Parkville, Victoria, Australia.,Cardiac Regeneration, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Gabrielle M Haeusler
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics and Critical Care, University of Melbourne, Parkville, Victoria, Australia.,The Paediatric Integrated Cancer Service, Parkville, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Royal Children's Hospital, Parkville, Victoria, Australia
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8
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Infections during Non-Neutropenic Episodes in Pediatric Cancer Patients—Results from a Prospective Study in Two Major Large European Cancer Centers. Antibiotics (Basel) 2022; 11:antibiotics11070900. [PMID: 35884154 PMCID: PMC9311840 DOI: 10.3390/antibiotics11070900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 12/04/2022] Open
Abstract
Whereas the clinical approach in pediatric cancer patients with febrile neutropenia is well established, data on non-neutropenic infectious episodes are limited. We therefore prospectively collected over a period of 4 years of data on all infectious complications in children treated for acute lymphoblastic or myeloid leukemia (ALL or AML) and non-Hodgkin lymphoma (NHL) at two major pediatric cancer centers. Infections were categorized as fever of unknown origin (FUO), and microbiologically or clinically documented infections. A total of 210 patients (median age 6 years; 142 ALL, 23 AML, 38 NHL, 7 leukemia relapse) experienced a total of 776 infectious episodes (571 during neutropenia, 205 without neutropenia). The distribution of FUO, microbiologically and clinically documented infections, did not significantly differ between neutropenic and non-neutropenic episodes. In contrast to neutropenic patients, corticosteroids did not have an impact on the infectious risk in non-neutropenic children. All but one bloodstream infection in non-neutropenic patients were due to Gram-positive pathogens. Three patients died in the context of non-neutropenic infectious episodes (mortality 1.4%). Our results well help to inform clinical practice guidelines in pediatric non-neutropenic cancer patients presenting with fever, in their attempt to safely restrict broad-spectrum antibiotics and improve the quality of life by decreasing hospitalization.
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9
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Wattier RL, Esbenshade AJ. From "More is Better" to "Less is More": A Commentary on Antimicrobial Use in Pediatric Oncology. J Pediatric Infect Dis Soc 2022; 11:229-238. [PMID: 35099542 DOI: 10.1093/jpids/piab111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/09/2021] [Indexed: 11/14/2022]
Abstract
Reducing avoidable antimicrobial exposure to pediatric patients with cancer is achievable and necessary to promote optimal short- and long-term outcomes. Multiple evidence-based practices are already well established but should be more consistently implemented. Important opportunities exist to further improve the evidence to guide selective antimicrobial use in pediatric oncology.
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Affiliation(s)
- Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California San Francisco, San Francisco, California, USA
| | - Adam J Esbenshade
- Department of Pediatrics, Division of Hematology/Oncology, Vanderbilt University, Nashville, Tennessee, USA
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10
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Gorfinkel L, Hansen CE, Teng W, Shabanova V, Prozora S, Rodwin R, Qadri U, Manghi T, Emerson B, Riera A. Clinical decision rule for obtaining peripheral blood cultures in febrile oncology patients. Pediatr Blood Cancer 2022; 69:e29519. [PMID: 34939321 DOI: 10.1002/pbc.29519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/08/2021] [Accepted: 11/22/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND The utility of peripheral blood cultures in pediatric oncology patients presenting with fever is controversial. A recent systematic review showed that about one in 40 bloodstream infections (BSIs) would be missed if only central venous line (CVL) cultures are obtained. OBJECTIVE To derive a clinical decision rule for obtaining peripheral blood cultures in pediatric oncology patients presenting to a pediatric emergency department (PED) with fever and a CVL. DESIGN/METHOD A retrospective chart review was performed on pediatric oncology patients referred to the PED for fever while on therapy. Logistic regression with a random intercept was used to determine independent predictors of BSI and generate a prediction model for obtaining peripheral blood cultures. The decision rule was generated from the best performance as measured by a receiver operator curve. Bootstrapping analysis was performed for internal validation. RESULTS Predictors that were significant and independently associated with positive peripheral blood cultures included vasopressor support (odds ratio [OR] 16.5, 95% confidence interval [CI]: 2.80-97.71), acute myeloid leukemia (AML) diagnosis (OR 6.9, 95% CI: 1.81-25.98), hypotension (OR 4.0, 95% CI: 1.05-15.17), mucositis (OR 8.2, 95% CI: 2.48-27.01), and maximum temperature in PED ≥39°C (OR 6.6, 95% CI: 2.36-18.20). The area under the curve (AUC) for this model was 0.90 (95% CI: 0.82-0.97) in the derivation cohort and 0.90 (95% CI: 0.81-0.98) after the internal validation. CONCLUSIONS We derived a clinical prediction model for deciding when to obtain peripheral blood cultures in febrile oncology patients with CVLs on active therapy. Future studies should focus on prospective and external validation of this diagnostic prediction tool.
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Affiliation(s)
- Lev Gorfinkel
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Caitlin E Hansen
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Wei Teng
- Yale New Haven Health, New Haven, CT, USA
| | - Veronika Shabanova
- Department of Biostatistics and Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Stephanie Prozora
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Yale School of Medicine, New Haven, CT, USA
| | - Rozalyn Rodwin
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Yale School of Medicine, New Haven, CT, USA
| | - Umar Qadri
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Tomas Manghi
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Beth Emerson
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Antonio Riera
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
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11
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Oh BLZ, Fan L, Lee SHR, Foo KM, Chiew KH, Seeto ZZL, Chen ZW, Neoh CCC, Liew GSM, Eng JJ, Lam JCM, Quah TC, Tan AM, Chan YH, Yeoh AEJ. Life-threatening infections during treatment for acute lymphoblastic leukemia on the Malaysia-Singapore 2003 and 2010 clinical trials: A risk prediction model. Asia Pac J Clin Oncol 2022; 18:e456-e468. [PMID: 35134276 DOI: 10.1111/ajco.13756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
AIM Life-threatening infections significantly impact the care of children undergoing therapy for acute lymphoblastic leukemia (ALL) who are at risk of severe sepsis due to both host and treatment factors. Our aim was to develop a life-threatening infection risk prediction model that would allow remote rapid triage of patients to reduce time to first dose of antibiotics and sepsis-related mortality. METHODS A retrospective analysis of 2068 fever episodes during ALL therapy was used for model building and subsequent internal validation. RESULTS Three hundred and seventy-seven patients were treated for ALL in two institutions with comparable critical and supportive care resources. A total of 55 patients accounted for 71 admissions to the critical care unit for sepsis that led to eight septic deaths during a 16-year study period. A retrospective analysis of risk factors for sepsis enabled us to build a model focused on 13 variables that discriminated admissions requiring critical care well: area under the receiver operating characteristic curve of .82; 95% CI .76-.87, p<.001, and Brier score of .033. Significant univariate predictors included neutropenia, presence of symptoms of abdominal pain, diarrhea, fever during induction or steroid-based phases, and the lack of any localizing source of infection at time of presentation. CONCLUSION We have developed a risk prediction model that can reliably identify ALL patients undergoing treatment who are at a higher risk of life-threatening sepsis. Clinical applicability can potentially be extended to low-middle income settings, and its utility should be further studied in real-world settings.
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Affiliation(s)
- Bernice L Z Oh
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Lijia Fan
- Division of Critical Care, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shawn H R Lee
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Koon Mian Foo
- Department of Paediatric Subspecialties Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
| | - Kean Hui Chiew
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Zelia Z L Seeto
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Zhi Wei Chen
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Cheryl C C Neoh
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore
| | - Germaine S M Liew
- Department of Paediatric Subspecialties Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
| | - Jing Jia Eng
- Department of Paediatric Subspecialties Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
| | - Joyce C M Lam
- Department of Paediatric Subspecialties Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
| | - Thuan Chong Quah
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Ah Moy Tan
- Department of Paediatric Subspecialties Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Allen E J Yeoh
- Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
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12
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Beauchemin M, Marshall AF, Ricci AM, Lopez I, Yao Y, Lee A, Jin Z, Sulis ML. Bacteremia in Febrile, Non-neutropenic, and Well-appearing Children With Cancer. J Pediatr Hematol Oncol 2022; 44:e194-e198. [PMID: 34001793 PMCID: PMC8599517 DOI: 10.1097/mph.0000000000002201] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/29/2021] [Indexed: 01/03/2023]
Abstract
Fever in a neutropenic pediatric oncology patient requires prompt assessment due to the risk of infectious complications. The appropriate management of fever in non-neutropenic patients, however, is not well-established. We describe the rate of bacteremia in a cohort of non-neutropenic pediatric oncology patients with fever at a large institution. Patients were included if they presented to the emergency department or outpatient clinic between 2009 and 2014 with fever, had a central venous catheter (CVC), and were not neutropenic. Three hundred eighty-six episodes of fever occurring in 159 patients were included in the data analysis. Fifty-nine percent of patients were male, 41% had a diagnosis of acute lymphoblastic leukemia, and 90% had a port-a-cath as CVC. The rate of bacteremia was 3.4%; presence of a port-a-cath was protective against bacteremia whereas a white blood cell count >20,000/mm3 was associated with a higher likelihood of bacteremia. Gram-positive microorganisms were most commonly isolated (64.3%) and frequently resistant to cephalosporins. In summary, in our study, the rate of bacteremia was low among non-neutropenic, well-appearing pediatric cancer patients with a CVC and was not associated with any serious medical complications. Prospective research is needed to determine the most appropriate management of these patients.
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Affiliation(s)
- Melissa Beauchemin
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation. Columbia University Irving Medical Center, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Alison Fernbach Marshall
- Pediatric Transplant Center, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA
| | - Angela M. Ricci
- Department of Pediatrics, Children’s Hospital at Dartmouth-Hitchcock, Lebanon, NH
| | - Ibis Lopez
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation. Columbia University Irving Medical Center, New York, NY
| | - Yujing Yao
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| | - Alice Lee
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation. Columbia University Irving Medical Center, New York, NY
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| | - Maria Luisa Sulis
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
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13
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Bergmann KR, Orchard PJ, Roback MG, Gaillard P, Furnival RA. Outcomes of Children Who Present to the Emergency Department After Hematopoietic Cell Transplantation. Pediatr Emerg Care 2021; 37:e1402-e1408. [PMID: 32097376 DOI: 10.1097/pec.0000000000002060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Our primary objective was to describe emergency department (ED) presentation, treatment, and outcomes for children after hematopoietic cell transplantation (HCT). Our secondary objective was to identify factors associated with serious infection in this population. METHODS This is a retrospective review of HCT patients who presented to our university children's hospital ED from January 1, 2011, to June 30, 2013. Emergency department presentation, treatment, and outcomes were described. Descriptive statistics were used to compare children with definite serious infection with those without serious infection. Multiple binary logistic regression was performed for risk factors associated with definite serious infection. RESULTS Fifty-four HCT patients (132 encounters) presented to our ED. Most were transplanted for a malignant (46%) or metabolic (36%) diagnosis and were recipients of bone marrow (51%) or umbilical cord blood (45%). Fever was the most common complaint (25%). Emergency department laboratory (64%) or imaging (58%) studies were frequently obtained. Admission was common (n = 70/132, 53%), with 79% (n = 55) of admissions to intensive care or bone marrow transplant units. Thirty-five encounters had definite serious infection, 5 had probable serious infection, and 92 had no serious infection. Fever (P < 0.001) and high-risk white blood cell (WBC) count of less than 5 or greater than 15 k/μL (P < 0.001) were associated with definite serious infection. Fever (odds ratio = 8.84, 95% confidence interval = 2.92-26.73) and high-risk WBC (odds ratio = 6.67, 95% confidence interval = 2.24-19.89) remained significantly associated with definite serious infection in our regression model. CONCLUSIONS Children presenting to the ED after HCT require extensive support and resources, with more than half requiring admission. Fever and high-risk WBC are associated with serious infection.
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Affiliation(s)
| | - Paul J Orchard
- Division of Blood and Marrow Transplantation, Department of Pediatrics
| | - Mark G Roback
- Division of Emergency Medicine, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Philippe Gaillard
- Department of Mathematics and Statistics, Auburn University, Auburn, AL
| | - Ronald A Furnival
- Division of Emergency Medicine, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
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14
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Vandenberk M, De Bondt K, Nuyts E, Toelen J, Verbakel JY. Shivering has little diagnostic value in diagnosing serious bacterial infection in children: a systematic review and meta-analysis. Eur J Pediatr 2021; 180:1033-1042. [PMID: 33179117 DOI: 10.1007/s00431-020-03870-7] [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: 08/15/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 11/28/2022]
Abstract
Early diagnosis of serious bacterial infections (SBI) is important for improving outcome of morbidity and mortality in children. A systematic review was conducted to examine if shivering had any value in diagnosing serious bacterial infection. We split our population (0-18 years old) into two categories depending on the presence of a known malignancy. The databases of Medline, Embase, Cinahl, and Web of Science were searched from inception until July 2019. The quality was assessed with the QUADAS-2 tool. Two by two tables were created, extracting the number of true positive (TP), true negative (TN), false positive (FP), and false negative (FN) regarding shivering and SBI, by 2 authors independently. Sensitivity, specificity, likelihood ratios, and their 95% confidence intervals were calculated using the MetaDATA Shiny app. In a population with known malignancy, we found a +LR of 3.47 (95% CI 2.58-4.36) for a serious bacterial infection when shivering was present, implying an increase of 25-30% possibility for a serious bacterial infection. In children without malignancy, diagnostic accuracy of shivering was poor.Conclusion: Shivering is of limited use to diagnose serious bacterial infection in children without malignancy. Nevertheless, in children with known malignancy, it can be useful as an alarm signal. What is Known: • In the NICE guidelines for febrile illness in children, "shivering" is considered as an intermediate risk factor ("amber" sign) for a serious illness. • A systematic literature search conducted in 2007 investigating the correlation between shivering in a febrile child and the presence of a serious bacterial infection could include only one study. What is New: • Based on the results of this systematic review, shivering has little diagnostic value in children without malignancy but can be useful as an alarm sign of serious bacterial infection in children with known malignancy. • In case of absence of shivering, serious bacterial infection cannot be ruled out.
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Affiliation(s)
| | | | - Emma Nuyts
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jaan Toelen
- Department of Pediatrics, Division of Woman and Child, UZ Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jan Y Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium. .,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
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15
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Sharma A, Sitthi-amorn J, Gavigan P, Wolf J, Agulnik A, Brenner A, Li Y, Johnson LM. Outcomes and Disposition of Oncology Patients With Non-neutropenic Fever and Positive Blood Cultures. J Pediatr Hematol Oncol 2021; 43:47-51. [PMID: 32604334 PMCID: PMC7762736 DOI: 10.1097/mph.0000000000001878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/26/2020] [Indexed: 11/25/2022]
Abstract
Children with cancer and non-neutropenic fever (NNF) episodes are often treated as outpatients if they appear well. However, a small subset have bloodstream infections (BSIs) and must return for further evaluation. These patients may be directly admitted to inpatient units, whereas others are first evaluated in outpatient settings before admission. The best practice for securing care for patients discovered to have outpatient bacteremia are unclear. To determine outcomes and compare time to antibiotics between the 2 disposition, we retrospectively reviewed all NNF initially treated as outpatients and later had positive blood cultures from 2012 to 2016. Of 845 NNF cases initially treated in outpatient settings, 48 episodes (n=43 patients) had BSIs. Of those, 77.1% (n=37) were re-evaluated as outpatients and admitted; 14.6% (n=7) were direct admissions. The median time to antibiotic did not significantly differ between outpatient re-evaluations (119 min) and direct admissions (191 min), P=0.11. One patient met sepsis criteria upon return and required intensive care unit admission for vasopressor support. No patient died within 1 week of the febrile episode. Most patients with NNF and BSIs initially discharged are stable upon return. Institutions should evaluate their patient flows to ensure that patients receive timely care.
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Affiliation(s)
- Aditya Sharma
- Hospitalist Medicine Program, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jitsuda Sitthi-amorn
- Hospitalist Medicine Program, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Patrick Gavigan
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA
| | - Joshua Wolf
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN
| | - Alex Brenner
- College of Medicine, Florida State University, Tallahassee, FL
| | - Ying Li
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN
| | - Liza-Marie Johnson
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
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16
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Shinn K, Wetzel M, DeGroote NP, Keller F, Briones M, Felker J, Castellino S, Miller TP. Impact of respiratory viral panel testing on length of stay in pediatric cancer patients admitted with fever and neutropenia. Pediatr Blood Cancer 2020; 67:e28570. [PMID: 32881268 PMCID: PMC7721999 DOI: 10.1002/pbc.28570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Polymerase chain reaction (PCR) respiratory viral panel (RVP) testing is often used in evaluation of pediatric cancer patients with febrile neutropenia (FN), but correlation with adverse outcomes has not been well characterized. PROCEDURE A retrospective cohort of all children ages 0-21 years with cancer admitted to Children's Healthcare of Atlanta for FN from January 2013 to June 2016 was identified. Patient demographic and clinical variables such as age, RVP results, length of stay (LOS), and deaths were abstracted. Relationship between RVP testing and positivity and LOS, highest temperature (Tmax), hypotension and intensive care unit (ICU) admission were compared using Wilcoxon rank sums, chi-square, or Fisher's exact tests adjusting for age, sex, bacteremia, and diagnosis. RESULTS The 404 patients identified had 787 total FN admissions. RVPs were sent in 38% of admissions and were positive in 59%. Patients with RVPs sent were younger (median 5.5 vs 8.0 years, P < .0001) with higher Tmax (39.2° vs 39.1°, P = .016). The most common virus identified was rhinovirus/Enterovirus (61%). There were no significant differences in highest temperature or lowest blood pressure based on RVP positivity. Patients admitted to the ICU were more likely to have RVPs sent (odds ratio [OR] = 3.19, P < .002); however, neither having RVP testing nor RVP positivity were significantly associated with increased LOS or death. Coinfection with bacteremia and a respiratory virus was identified in 9.1% of patients. CONCLUSIONS These data raise the question of the utility of sending potentially costly RVP testing as RVP positivity during febrile neutropenia does not impact LOS, degree of hypotension, or ICU admission.
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Affiliation(s)
| | - Martha Wetzel
- Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Nicholas P. DeGroote
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Frank Keller
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA;,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Michael Briones
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA;,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - James Felker
- Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Sharon Castellino
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA;,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Tamara P. Miller
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA;,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
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17
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Esbenshade AJ, Zhao Z, Baird A, Holmes EA, Dulek DE, Banerjee R, Friedman DL. Prospective Implementation of a Risk Prediction Model for Bloodstream Infection Safely Reduces Antibiotic Usage in Febrile Pediatric Cancer Patients Without Severe Neutropenia. J Clin Oncol 2020; 38:3150-3160. [PMID: 32762614 DOI: 10.1200/jco.20.00591] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Management of febrile pediatric patients with cancer with an absolute neutrophil count of 500/µL or greater is unclear. The Esbenshade Vanderbilt (EsVan) risk prediction models have been shown to predict bloodstream infection (BSI) likelihood in this population, and this study sought to prospectively validate and implement these models in clinical practice. METHODS Data were prospectively collected on febrile pediatric patients with cancer with a central venous catheter from April 2015 to August 2019 at a single site, at which the models (EsVan: 2015 to 2017; EsVan2: October 2017 to 2019) were initially developed and subsequently implemented for clinical management in well-appearing nonseverely neutropenic individuals. It was recommended that patients with low BSI risk (< 10%) be discharged home without antibiotics, those with intermediate BSI risk (10%-39.9%) be administered an antibiotic before discharge, and those with high BSI risk (> 40%) be admitted on broad-spectrum antibiotics. Seven-day outcomes were then collected and EsVan models were prospectively validated and C-statistics estimated. RESULTS In 937 febrile, nonsevere neutropenia episodes, frequencies of low-, intermediate-, and high-risk episodes were 88.9%, 8.6%, and 2.3% respectively. BSI incidence was 4.2% (39 of 937). Within risk groups, low-risk BSI incidence was 1.9% (16 of 834) with BSI incidence of 13.6% and 54.5% for intermediate- and high-risk episodes, respectively. Empirical intravenous antibiotics were administered in 21.1% of low-risk episodes at presentation and at 7 days postpresentation, 72.3% of episodes never required intravenous antibiotics. There were no deaths or clinical decompensations attributable to antibiotic delay. For BSI detection, EsVan and EsVan2 models applied to the new cohort achieved C-statistics of 0.802 and 0.824, respectively. CONCLUSION Prospective, real-time clinical utilization of the EsVan models accurately predicts BSI risk and safely reduces unnecessary antibiotic use in febrile, nonseverely neutropenic pediatric patients with cancer.
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Affiliation(s)
- Adam J Esbenshade
- Vanderbilt University School of Medicine, Nashville, TN.,Vanderbilt-Ingram Cancer Center, Nashville, TN.,Division of Pediatric Hematology-Oncology, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Alaina Baird
- Division of Pediatric Hematology-Oncology, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | | | - Daniel E Dulek
- Vanderbilt University School of Medicine, Nashville, TN.,Division of Pediatric Infectious Disease, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Ritu Banerjee
- Vanderbilt University School of Medicine, Nashville, TN.,Division of Pediatric Infectious Disease, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Debra L Friedman
- Vanderbilt University School of Medicine, Nashville, TN.,Vanderbilt-Ingram Cancer Center, Nashville, TN.,Division of Pediatric Hematology-Oncology, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
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Paul M, Bhatia M, Rekha US, Omar BJ, Gupta P. Microbiological Profile of Blood Stream Infections in Febrile Neutropenic Patients at a Tertiary Care Teaching Hospital in Rishikesh, Uttarakhand. J Lab Physicians 2020; 12:147-153. [PMID: 32905287 PMCID: PMC7467830 DOI: 10.1055/s-0040-1716661] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Context Febrile neutropenia is a serious complication of chemotherapy affecting patients with both hematological and solid malignancies, respectively. To the best of our knowledge, there is paucity of literature from Uttarakhand, India on microbiological profile of blood stream infections (BSIs) in febrile neutropenic patients. Aims The study aims to generate preliminary data on microbiological profile and antibiotic resistance pattern of BSIs in febrile neutropenic patients. Settings and Design The design involved cross-sectional study from January 1, 2019 to July 31, 2019. Methods and Materials Data of nonrepetitive paired peripheral blood samples obtained from 306 consecutive febrile neutropenic cancer patients of all age groups and both sexes, for culture and sensitivity testing, were retrospectively analyzed. All blood samples were subjected to aerobic culture using BACT/ALERT three-dimensional microbial detection system. Growth obtained in culture was identified by conventional biochemical methods. Antibiotic susceptibility testing of bacterial isolates was performed using modified Kirby Bauer disk diffusion method. Statistical Analysis Used Fisher's exact test was used for the analysis. Results Mean age ± SD of the study population was 32.39 ± 10.56 years with a male to female ratio of 1.55:1. 74.18% of the blood samples were received from patients suffering from hematological malignancies. Microbiologically confirmed BSIs were observed in 27.1% patients. Gram-negative bacilli were predominantly isolated in culture with Klebsiella spp . being the most common. Percentage resistance values of gram-negative bacilli to aminoglycosides, β-lactam/β-lactamase inhibitor combinations, fluoroquinolones, cephalosporins, carbapenems, chloramphenicol, ampicillin, co-trimoxazole, and doxycycline were 26.6 to 91.7%, 8.3 to 86.6%, 10 to 66.7%, 13.3 to 73.3%, 8.3 to 73.3%, 80 to 93.3%, 13.3 to 20%, 16.7 to 66.6%, and 13.3 to 16.7%, respectively. Conclusion Implementation of antimicrobial stewardship program along with hospital infection control practices is needed for preventing BSIs due to MDR organisms.
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Affiliation(s)
- Manisha Paul
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Mohit Bhatia
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Udayakumar Sasi Rekha
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | | | - Balram Ji Omar
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Pratima Gupta
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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19
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AlAzmi A, Jastaniah W, AlDabbagh M, Elimam N. A clinical approach to non-neutropenic fever in children with cancer. J Oncol Pharm Pract 2020; 27:560-569. [PMID: 32476589 DOI: 10.1177/1078155220925161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There are a limited number of studies that address non-neutropenic fever episodes in children with cancer, and no standard approach exists. METHOD We opt to retrospectively analyze the efficacy of the current clinical approach for management of non-neutropenic fever episodes and the associated risk factors among children with cancer at the Princess Noorah Oncology Center from May 2016 through December 2017. RESULTS A total of 480 non-neutropenic fever episodes were identified in 131 children, of which 62 episodes were triaged as high-risk non-neutropenic fever and 418 as low-risk non-neutropenic fever. Of those 480 non-neutropenic fever, 361 episodes (75.2%) were associated with the presence of central venous catheters. The overall failure rate of ceftriaxone mono-therapy was observed in 75.6% (11.7% in high-risk non-neutropenic fever with a mean C-reactive protein level of 21.1 (±23.2) mmol/L and 63.9% in low-risk non-neutropenic fever with a mean C-reactive protein level of 17.6 (±53.9) mmol/L). The overall bacteremia rate was 14.4%. The type of organisms isolated was mainly high-risk organisms in 59 non-neutropenic fever episodes (85.5%), OR 1.78 (95% CI: 0.45-7.04) p = 0.41. Of note, all bacteremia were associated with the presence of central venous catheter (100%). Of all the examined risk factors of outpatient treatment failure in low-risk non-neutropenic fever, only prolonged fever of more than three days were significantly associated with bacteremia OR 8.107 [95% CI: 1.744-37.691], p = 0.008. Noteworthy is that almost 43% of non-neutropenic fever episodes were associated with respiratory symptoms. This study provides a baseline for future prospective research assessing the pattern of non-neutropenic fever by focusing on associated risk factors.
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Affiliation(s)
- Aeshah AlAzmi
- Department of Pharmaceutical Care Clinical Services, King Abdulaziz Medical City, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Faculty of Medicine, Jeddah, Saudi Arabia
- Department of Pediatrics, Oncology/Hematology/BMT, Princes Noorah Oncology Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Wasil Jastaniah
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Faculty of Medicine, Jeddah, Saudi Arabia
- Department of Pediatrics, Oncology/Hematology/BMT, Princes Noorah Oncology Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
- Department of Pediatrics, Faculty of Medicine, Umm AlQura University, Makkah, Saudi Arabia
| | - Mona AlDabbagh
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Faculty of Medicine, Jeddah, Saudi Arabia
- Department of Pediatrics, Division of Infectious diseases, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Naglla Elimam
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Faculty of Medicine, Jeddah, Saudi Arabia
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20
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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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21
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Haeusler GM, Thursky KA, Slavin MA, Babl FE, De Abreu Lourenco R, Allaway Z, Mechinaud F, Phillips R. Risk stratification in children with cancer and febrile neutropenia: A national, prospective, multicentre validation of nine clinical decision rules. EClinicalMedicine 2020; 18:100220. [PMID: 31993576 PMCID: PMC6978200 DOI: 10.1016/j.eclinm.2019.11.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/12/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Reduced intensity treatment of low-risk febrile neutropenia (FN) in children with cancer is safe and improves quality of life. Identifying children with low-risk FN using a validated risk stratification strategy is recommended. This study prospectively validated nine FN clinical decision rules (CDRs) designed to predict infection or adverse outcome. METHODS Data were collected on consecutive FN episodes in this multicentre, prospective validation study. The reproducibility and discriminatory ability of each CDR in the validation cohort was compared to the derivation dataset and details of missed outcomes were reported. FINDINGS There were 858 FN episodes in 462 patients from eight hospitals included. Bacteraemia occurred in 111 (12·9%) and a non-bacteraemia microbiological documented infection in 185 (21·6%). Eight CDRs exhibited reproducibility and sensitivity ranged from 64% to 96%. Rules that had >85% sensitivity in predicting outcomes classified few patients (<20%) as low risk. For three CDRs predicting a composite outcome of any bacterial or viral infection, the sensitivity and discriminatory ability improved for prediction of bacterial infection alone. Across all CDRs designed to be implemented at FN presentation, the sensitivity improved at day 2 assessment. INTERPRETATION While reproducibility was observed in eight out of the nine CDRs, no rule perfectly differentiated between children with FN at high or low risk of infection. This is in keeping with other validation studies and highlights the need for additional safeguards against missed infections or adverse outcomes before implementation can be considered.
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Affiliation(s)
- Gabrielle M. Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- The Victorian Paediatric Integrated Cancer Service, Victoria State Government, Melbourne, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
- Corresponding author at: Department of Infectious Diseases, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne 3000, Australia.
| | - Karin A. Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Monica A. Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Franz E. Babl
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT)
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Zoe Allaway
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Francoise Mechinaud
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Unité d'hématologie immunologie pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, France
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, United Kingdom
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22
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Chen S, Liu S, Yuan X, Mai H, Lin J, Wen F. Etiology, drug sensitivity profiles and clinical outcome of bloodstream infections: A retrospective study of 784 pediatric patients with hematological and neoplastic diseases. Pediatr Hematol Oncol 2019; 36:482-493. [PMID: 31718370 DOI: 10.1080/08880018.2019.1667462] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Bloodstream infections (BSI) represent one of the most serious complications in patients in the hematology-oncology unit. In this study, the prevalence, distribution, drug sensitivity profiles, and clinical outcome of BSI were analyzed in pediatric patients with hematological malignancies. Patients admitted to the pediatric hematology-oncology unit at Shenzhen Children's Hospital (Shenzen, China) between January 2016 and December 2017 were enrolled. Their medical records, including gender, age, primary diseases, and microbiology results of all clinical specimens, were reviewed. The incidence of BSI, microbiology characteristics, and effectiveness of antimicrobial therapy were analyzed. A total of 125 BSI cases in 108 patients (mean age, 5.5 years) were recorded, of which 69 (55.2%) were nosocomial BSI cases. The overall rate of BSI was 18.8% in the hematology-oncology unit, of which 75 (75.2%) episodes were neutropenic patients. Patients with nosocomial BSIs and the neutropenic group were older (p#.02, p#.03). HSCTs and AML were more often observed in nosocomial BSIs, while solid tumors were more found in nonnosocomial and non-neutropenic BSIs. BSIs were dominated by Gram-negative pathogens (49.6%) in the hematology-oncology unit compared with Gram-positive pathogens (39.2%). The most common pathogens were coagulase-negative Staphylococcus (24.2%) followed by Klebsiella pneumonia (15.2%), Escherichia coli (12.5%), viridans streptococci (8.2%), and Candida species (7.8%). The antibiotic therapy success rate in patients was 93.5%. Based on our center's experience, Gram-negative pathogens were commonly observed among pediatric hematology-oncology patients with BSI. Coagulase-negative Staphylococcus and K. pneumoniae predominated and antibiotic therapy was effective in these patients.
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Affiliation(s)
- Senmin Chen
- Department of Pediatrics, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Hematology and Oncology Department, Shenzhen Children's Hospital, Shenzhen, China
| | - Sixi Liu
- Hematology and Oncology Department, Shenzhen Children's Hospital, Shenzhen, China
| | - Xiuli Yuan
- Hematology and Oncology Department, Shenzhen Children's Hospital, Shenzhen, China
| | - Huirong Mai
- Hematology and Oncology Department, Shenzhen Children's Hospital, Shenzhen, China
| | - Junrong Lin
- Hematology and Oncology Department, Shenzhen Children's Hospital, Shenzhen, China
| | - Feiqiu Wen
- Department of Pediatrics, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Hematology and Oncology Department, Shenzhen Children's Hospital, Shenzhen, China
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23
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Allaway Z, Phillips RS, Thursky KA, Haeusler GM. Nonneutropenic fever in children with cancer: A scoping review of management and outcome. Pediatr Blood Cancer 2019; 66:e27634. [PMID: 30724005 DOI: 10.1002/pbc.27634] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/17/2018] [Accepted: 01/10/2019] [Indexed: 12/17/2022]
Abstract
To date, very few studies have addressed nonneutropenic fever (NNF) in children with cancer, and there are no consensus guidelines. This scoping review aims to describe the rate of bacteremia, risk factors for infection and management, and outcomes of NNF in this population. Across 15 studies (n = 4106 episodes), the pooled-average bacteremia rate was 8.2%, and risk factors included tunneled external central venous catheter, clinical instability, and higher temperature. In two studies, antibiotics were successfully withheld in a subset of low-risk patients. Overall outcomes of NNF appear favorable; however, further research is required to determine its true clinical and economic impact.
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Affiliation(s)
- Zoe Allaway
- The Paediatric Integrated Cancer Service, Parkville, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Robert S Phillips
- Centre for Reviews and Dissemination, University of York, Heslington, York, UK.,Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.,NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Gabrielle M Haeusler
- The Paediatric Integrated Cancer Service, Parkville, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.,NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,Infectious Diseases Unit, Department of General Paediatrics, The Royal Children's Hospital, Parkville, Victoria, Australia
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24
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Wu N, Muller W, Morgan E. Outcomes of observation without empiric intravenous antibiotics in febrile, nonneutropenic pediatric oncology patients. Pediatr Blood Cancer 2019; 66:e27550. [PMID: 30478977 DOI: 10.1002/pbc.27550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 11/07/2022]
Abstract
There are no consensus guidelines for management of pediatric oncology patients presenting with fever and nonneutropenia, with limited research into the outcomes of withholding empiric i.v. antibiotics. We conducted a prospective cohort study assessing the safety and efficacy of observing well-appearing patients presenting with fever and nonneutropenia (absolute neutrophil count ≥ 500 cells/mm3 ). Of 238 episodes, 82.7% patients were observed with no infectious complications and low overall incidence of bacteremia (3.4%). There were no significant differences in individual clinical variables. We propose that observation alone in some well-appearing febrile pediatric oncology patients is safe and limits the use of unnecessary empiric antibiotics.
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Affiliation(s)
- Natalie Wu
- Division of Hospital Based Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - William Muller
- Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Elaine Morgan
- Division of Hematology, Oncology, & Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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25
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Esbenshade AJ, Zhao Z, Aftandilian C, Saab R, Wattier RL, Beauchemin M, Miller TP, Wilkes JJ, Kelly MJ, Fernbach A, Jeng M, Schwartz CL, Dvorak CC, Shyr Y, Moons KGM, Sulis ML, Friedman DL. Multisite external validation of a risk prediction model for the diagnosis of blood stream infections in febrile pediatric oncology patients without severe neutropenia. Cancer 2017; 123:3781-3790. [PMID: 28542918 DOI: 10.1002/cncr.30792] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/24/2017] [Accepted: 04/24/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pediatric oncology patients are at an increased risk of invasive bacterial infection due to immunosuppression. The risk of such infection in the absence of severe neutropenia (absolute neutrophil count ≥ 500/μL) is not well established and a validated prediction model for blood stream infection (BSI) risk offers clinical usefulness. METHODS A 6-site retrospective external validation was conducted using a previously published risk prediction model for BSI in febrile pediatric oncology patients without severe neutropenia: the Esbenshade/Vanderbilt (EsVan) model. A reduced model (EsVan2) excluding 2 less clinically reliable variables also was created using the initial EsVan model derivative cohort, and was validated using all 5 external validation cohorts. One data set was used only in sensitivity analyses due to missing some variables. RESULTS From the 5 primary data sets, there were a total of 1197 febrile episodes and 76 episodes of bacteremia. The overall C statistic for predicting bacteremia was 0.695, with a calibration slope of 0.50 for the original model and a calibration slope of 1.0 when recalibration was applied to the model. The model performed better in predicting high-risk bacteremia (gram-negative or Staphylococcus aureus infection) versus BSI alone, with a C statistic of 0.801 and a calibration slope of 0.65. The EsVan2 model outperformed the EsVan model across data sets with a C statistic of 0.733 for predicting BSI and a C statistic of 0.841 for high-risk BSI. CONCLUSIONS The results of this external validation demonstrated that the EsVan and EsVan2 models are able to predict BSI across multiple performance sites and, once validated and implemented prospectively, could assist in decision making in clinical practice. Cancer 2017;123:3781-3790. © 2017 American Cancer Society.
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Affiliation(s)
- Adam J Esbenshade
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.,Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee.,Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Zhiguo Zhao
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University, Nashville, Tennessee.,Center for Quantitative Science, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Catherine Aftandilian
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Raya Saab
- Department of Pediatrics, Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rachel L Wattier
- Department of Pediatrics, University of California at San Francisco, San Francisco, California
| | - Melissa Beauchemin
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, Columbia University, New York, New York
| | - Tamara P Miller
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer J Wilkes
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael J Kelly
- Division of Pediatric Hematology/Oncology, The Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts
| | - Alison Fernbach
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, Columbia University, New York, New York
| | - Michael Jeng
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Cindy L Schwartz
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher C Dvorak
- Department of Pediatrics, University of California at San Francisco, San Francisco, California
| | - Yu Shyr
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University, Nashville, Tennessee.,Center for Quantitative Science, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karl G M Moons
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Maria-Luisa Sulis
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, Columbia University, New York, New York
| | - Debra L Friedman
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.,Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee.,Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
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26
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Bacteremia in nonneutropenic pediatric oncology patients with central venous catheters in the ED. Am J Emerg Med 2016; 35:20-24. [PMID: 27765482 DOI: 10.1016/j.ajem.2016.09.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/10/2016] [Accepted: 09/12/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine clinical characteristics associated with bacteremia in febrile nonneutropenic pediatric oncology patients with central venous catheters (CVCs) in the emergency department (ED). BACKGROUND Fever is the primary reason pediatric oncology patients present to the ED. The literature states that 0.9% to 39% of febrile nonneutropenic oncology patients are bacteremic, yet few studies have investigated infectious risk factors in this population. METHODS This was a retrospective cohort study in a pediatric ED, reviewing medical records from 2002 to 2014. Inclusion criteria were patients with cancer, temperature at least 38°C, presence of a CVC, absolute neutrophil count greater than 500 cells/μL, and age less than 22 years. Exclusion criteria were repeat ED visits within 72 hours, bloodwork results not reported by the laboratory, and patients without oncologic history documented at the study hospital. The primary outcome measure is a positive blood culture (+BC). Other variables include age, sex, CVC type, cancer diagnosis, absolute neutrophil count, vital signs, upper respiratory infection (URI) symptoms, and amount of intravenous (IV) normal saline (NS) administered in the ED. Data were analyzed using descriptive statistics and a multiple logistic regression model. RESULTS A total of 1322 ED visits were sampled, with 534 enrolled, and 39 visits had +BC (7.3%). Variables associated with an increased risk of +BC included the following: absence of URI symptoms (odds ratio [OR], 2.30; 95% CI, 1.13-4.69), neuroblastoma (OR, 3.65; 95% CI, 1.47-9.09), "other" cancer diagnosis (OR, 4.56; 95% CI, 1.93-10.76), tunneled externalized CVC (OR, 5.04; 95% CI, 2.25-11.28), and receiving at least 20 mL/kg IV NS (OR, 2.34; 95% CI, 1.2-4.55). The results of a multiple logistic regression model also showed these variables to be associated with +BC. CONCLUSION The absence of URI symptoms, presence of an externalized CVC, neuroblastoma or other cancer diagnosis, and receiving at least 20 mL/kg IV NS in the ED are associated with increased risk of bacteremia in nonneutropenic pediatric oncology patients with a CVC.
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Ali BA, Hirmas N, Tamim H, Merabi Z, Hanna-Wakim R, Muwakkit S, Abboud M, Solh HE, Saab R. Approach to Non-Neutropenic Fever in Pediatric Oncology Patients-A Single Institution Study. Pediatr Blood Cancer 2015; 62:2167-71. [PMID: 26175012 DOI: 10.1002/pbc.25660] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/17/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pediatric oncology patients with fever, even when not neutropenic, are known to be at an increased risk of bloodstream infections. However, there are no standard guidelines for management of fever in non-neutropenic patients, resulting in variability in practice across institutions. PROCEDURE We retrospectively analyzed the clinical characteristics, management, and outcome of all febrile non-neutropenic episodes in pediatric oncology patients at a single institution over the two-year period 2011-2012, to identify predictors of bloodstream infections. We assessed the efficacy of a uniform approach to outpatient management of a defined subset of patients at low risk of invasive infections. RESULTS A total of 254 episodes in 83 patients were identified. All patients had implanted central venous catheters (port). Sixty-two episodes (24%) were triaged as high-risk and admitted for inpatient management; five (8%) had positive blood cultures. The remaining 192 episodes were triaged as low risk and managed with once daily outpatient intravenous ceftriaxone; three (1.6%) were associated with bacteremia, and 10% required eventual inpatient management. Of all the factors analyzed, only signs of sepsis (lethargy, chills, hypotension) were associated with positive bloodstream infection. CONCLUSIONS Treatment of a defined subset of patients with outpatient intravenous ceftriaxone was safe and effective. Signs of sepsis were the only factor significantly associated with bloodstream infection. This study provides a baseline for future prospective studies assessing the safety of withholding antibiotics in this subset of patients.
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Affiliation(s)
- Bilal Abou Ali
- Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon.,Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nader Hirmas
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Tamim
- Department of Internal Medicine, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Zeina Merabi
- Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rima Hanna-Wakim
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Samar Muwakkit
- Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon.,Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Miguel Abboud
- Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon.,Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hassan El Solh
- Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon.,Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Raya Saab
- Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon.,Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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