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Penkert RR, Jones BG, Tang L, Su Y, Jeha S, Yang J, Yang W, Ferrolino J, Strength R, Pui CH, Cross SJ, Hurwitz JL, Wolf J. Association of Vitamin A and D Deficiencies with Infectious Outcomes in Children Undergoing Intensive Induction Therapy for Acute Lymphoblastic Leukemia. J Pediatr 2024; 273:114148. [PMID: 38880379 DOI: 10.1016/j.jpeds.2024.114148] [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: 03/27/2024] [Revised: 05/21/2024] [Accepted: 06/11/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE To evaluate the association between deficiency of vitamin A or D at diagnosis of pediatric acute lymphoblastic leukemia (ALL) and subsequent infectious complications during induction therapy. STUDY DESIGN We conducted an institutional review board-approved, retrospective cohort study of children with newly diagnosed ALL from 2007 to 2017 at St. Jude Children's Research Hospital. We measured vitamin D, vitamin D binding protein, retinol binding protein as a surrogate for vitamin A, and immunoglobulin isotypes in serum obtained at ALL diagnosis, and we assessed the association between vitamin deficiencies or levels and infection-related complications during the 6-week induction phase using Cox regression models. RESULTS Among 378 evaluable participants, vitamin A and D deficiencies were common (43% and 17%, respectively). Vitamin D deficiency was associated with higher risks of febrile neutropenia (adjusted hazard ratio [aHR], 1.7; P = .0072), clinically documented infection (aHR, 1.73; P = .025), and likely bacterial infection (aHR, 1.86; P = .008). Conversely, vitamin A deficiency was associated solely with a lower risk of sepsis (aHR, 0.19; P = .027). CONCLUSIONS In this retrospective study, vitamin D deficiency was associated with an increased risk of common infection-related complications during induction therapy for ALL. Additional studies are warranted to evaluate whether vitamin D supplementation could mitigate this effect.
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Affiliation(s)
- Rhiannon R Penkert
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Bart G Jones
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Li Tang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Yin Su
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Sima Jeha
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN; Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Jun Yang
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Wenjian Yang
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Jose Ferrolino
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Rachel Strength
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Ching-Hon Pui
- 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
| | - Julia L Hurwitz
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN.
| | - 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.
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Diamond Y, Gilsenan M, Wang SS, Hanna D, Conyers R, Cole T, Hughes D, Fleming J, Meyran D, Toro C, Malalasekera V, Khaw SL, Haeusler GM. Infections in children following chimeric antigen receptor T-cell therapy for B-cell acute lymphoblastic leukemia. Transpl Infect Dis 2023; 25:e14202. [PMID: 38041799 DOI: 10.1111/tid.14202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/17/2023] [Accepted: 11/12/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND CD19-directed chimeric antigen receptor T-cell (CAR-T) therapy is transforming care for pediatric patients with relapsed or refractory B-cell acute lymphoblastic leukemia (B-ALL). There are limited pediatric-specific data concerning the infection risks associated with CD19 CAR-T therapy and the adequacy of current antimicrobial prophylaxis guidelines for these patients. METHODS We describe the antimicrobial prophylaxis used and the types of infectious occurring in the first 100 days following CAR-T therapy for relapsed or refractory B-cell ALL in children and adolescents (≤18 years) at our centre. RESULTS Twenty-seven patients received their first CAR-T infusion (CTI) during the study period. Almost all patients (96%) had a comprehensive Infectious Diseases review prior to CTI, which informed a personalised prophylaxis or fever/sepsis plan in six (22%). Overall, six (22%) patients had one or more infections during the study period including five (19%, 0.9 per 100 days-at-risk) from days 0-30 and three (n = 20, 15%, 0.6 per 100 days-at-risk) from days 31-100. Bacterial blood stream infections were the most common type of infection encountered during both time periods, and one patient had probable pulmonary aspergillosis. There were no infection-related deaths. CONCLUSION Our study contributes important information on the spectrum of infections encountered in pediatric patients with B-ALL post CAR-T therapy. Overall, the burden of infectious complications post CAR-T therapy in our cohort is lower than previously reported in the literature. Results suggest that our prophylaxis recommendations are effective in this population.
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Affiliation(s)
- Yonatan Diamond
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Maddie Gilsenan
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Stacie Shiqi Wang
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Diane Hanna
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Rachel Conyers
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Theresa Cole
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - David Hughes
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Jacqueline Fleming
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Deborah Meyran
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Claudia Toro
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Paediatric Integrated Cancer Service, Victoria, Victoria, Australia
| | | | - Seong Lin Khaw
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Gabrielle M Haeusler
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Paediatric Integrated Cancer Service, Victoria, Victoria, Australia
- Department of Infectious Diseases, Royal Children's Hospital, Parkville, Victoria, Australia
- 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, Parkville, Victoria, Australia
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Alali M, Prather C, Danziger-Isakov LA, Kussin ML, Khalifeh M, Al Othman N, Bartlett AH. Absolute Monocyte Count as Early and Safe Marker for Antibiotic Cessation in Febrile Neutropenia Without Etiology in Pediatric Oncology Patients. J Pediatr Hematol Oncol 2023; 45:e702-e709. [PMID: 37494607 DOI: 10.1097/mph.0000000000002696] [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: 01/31/2023] [Accepted: 04/23/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND There is no practice standard regarding antibiotic duration in children with cancer and unexplained febrile neutropenia (FN). We hypothesized that absolute monocyte count (AMC) and absolute phagocyte count (APC= ANC + AMC + bands) are more sensitive, earlier, and safe markers of antibiotic cessation compared with absolute neutrophil count (ANC). METHODS A retrospective review of FN episodes (FNEs) in pediatric oncology patients was conducted between 2009 and 2016. Included patients were afebrile for 24 hours and without an identified infectious source at antibiotic cessation. Primary endpoints, including recurrent fever, readmission, bloodstream infection, microbiologically documented infection, and adverse outcomes, were assessed 10 days after antibiotic cessation and compared among different bone marrow recovery parameters (ANC, AMC, APC). Secondary endpoints included length of FN stay, antibiotic-free days, and cost. RESULTS Three hundred ninety-one FNEs in 235 patients were included. Three groups were compared based on ANC (cells/μL) at the time of antibiotic cessation: < 200 in 102 (26%), 200 to 500 in 111 (28%), and >500 in 178 (46%). No statistically significant differences in primary endpoints were identified among the 3 ANC groups; however, a trend toward unfavorable outcomes in the ANC ≤200 cells/μL group compared with the ANC >200 cells/μL was observed. Primary endpoints based on AMC >100 cells/μL at the time of antibiotic cessation showed statistically significant favorable outcomes compared AMC ≤100 cells/μL (80%, 88%, 90%, 89%, and 93% risk reduction in recurrent fever, readmission, new bloodstream infection, new microbiologically documented infection, and adverse events, respectively). Similar favorable results were seen when APC >300 cells/μL was used as a threshold for antibiotic cessation. The median length of stay for FN if discharged when AMC >100 cells/μL was 3 days shorter and associated with fewer unfavorable outcomes, thus resulting in fewer hospital days, fewer antibiotic days, and decreased cost. CONCLUSION Our results suggest that AMC >100 cells/μL (regardless of ANC) or APC >300 cells/μL may be safe thresholds for empiric antibiotic cessation and result in reduced unfavorable clinical outcomes within 10 days postdischarge, reduced antibiotic days of therapy and reduced health care costs. Further prospective studies are needed to validate AMC as an accurate surrogate marker for antibiotic cessation in FNEs in children with cancer.
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Affiliation(s)
- Muayad Alali
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Indiana University Health and Ryan White Center for Pediatric Infectious Diseases & Global Health
| | - Cassandra Prather
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Lara A Danziger-Isakov
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michelle L Kussin
- Department of Pharmacy Riley Hospital for Children at Indiana University Health and Ryan White Center for Pediatric Infectious Diseases & Global Health, Indiana University, Indianapolis, IN
| | - Malak Khalifeh
- Department of Biostatistics & Research, Stony Brook University, Stony Brook, NY
| | | | - Allison H Bartlett
- Division of Infectious Diseases, Department of Pediatrics, University of Chicago Medicine, Chicago, IL
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Andrew EC, Khaw SL, Hanna D, Conyers R, Fleming J, Hughes D, Toro C, Wang SS, Weerdenburg H, Anderson S, Cole T, Haeusler GM. Density of antibiotic use and infectious complications in pediatric allogeneic hematopoietic cell transplantation. Transpl Infect Dis 2023; 25:e14018. [PMID: 36748726 DOI: 10.1111/tid.14018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/16/2022] [Accepted: 12/11/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Antibiotics, while an essential component of supportive care in allogeneic hematopoietic cell transplantation (allo-HCT), can have adverse effects and select for antibiotic resistance. Understanding of patterns of use will inform antimicrobial stewardship (AMS) interventions. METHODS Retrospective, single-center cohort of children undergoing first allo-HCT (n = 125). Antibiotic prescription and infection data were included from the date conditioning was commenced until 30 days post allo-HCT. Antibiotic use was reported as length of therapy (LOT) (number of days a patient received an antibiotic) and days of therapy DOT (aggregating all antibiotics prescribed per day). Infections were classified as microbiologically documented infection (MDI) or clinically documented infections. RESULTS At least one course of antibiotics was administered to 124 (99%) patients. The LOT was 636 per 1000 patient days and DOT was 959 per 1000 patient days. The median duration of cumulative antibiotic exposure per patient was 24 days (interquartile range [IQR] 20-30 days). There were 131 days of fever per 1000 patient days with patients febrile for a median of 4 days (IQR 1-7 days). Piperacillin-tazobactam was used for 116 (94%) of patients with an LOT of 532 per 1000 patient days. A total of 119 MDI episodes occurred in 74 (59%) patients, including blood stream infection in 30 (24%) and a proven/probable invasive fungal infection in 4 (3%). CONCLUSION Pediatric HCT patients receive prolonged courses of broad-spectrum antibiotics relative to the frequency of fever and bacterial infections. This study has identified opportunities for AMS intervention to improve outcomes for our HCT patients.
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Affiliation(s)
- Eden C Andrew
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia
| | - Seong Lin Khaw
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia.,Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Diane Hanna
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia.,Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Rachel Conyers
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia.,Cardiac Regeneration Laboratory, Murdoch Children's Research Institute, Parkville, Australia
| | - Jacqueline Fleming
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia
| | - David Hughes
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia
| | - Claudia Toro
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia.,Cardiac Regeneration Laboratory, Murdoch Children's Research Institute, Parkville, Australia
| | - Stacie Shiqi Wang
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia.,Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Heather Weerdenburg
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia.,Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Sally Anderson
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia
| | - Theresa Cole
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia.,Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Gabrielle M Haeusler
- Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia.,Department of Infectious Diseases, Royal Children's Hospital, Parkville, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia.,Paediatric Integrated Cancer Service, Victoria, Australia
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Nowak M, Bobeff K, Walenciak J, Kołodrubiec J, Wyka K, Młynarski W, Trelińska J. One Hundred Consecutive Neutropenic Febrile Episodes Demonstrate That CXCR3 Ligands Have Predictive Value in Discriminating the Severity of Infection in Children with Cancer. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010039. [PMID: 36670590 PMCID: PMC9857223 DOI: 10.3390/children10010039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 12/11/2022] [Accepted: 12/15/2022] [Indexed: 12/28/2022]
Abstract
This study assesses the value of the CXCR3 ligands CXCL9/MIG, CXCL10/IP-10 and CXCL11/I-TAC when used to supplement the standard infection markers C-reactive protein (CRP) and procalcitonin (PCT) in the diagnostic algorithm of neutropenic fever in children with cancer. The concentration of CRP, PCT and chemokines was determined during the first hour of fever and 12-24 h afterwards in pediatric oncology patients with neutropenia. Among 100 consecutive febrile episodes in neutropenic patients, 34 cases demonstrated fever of unknown origin (FUO) (group A), 47 demonstrated mild clinically or microbiologically proven infection (Group B) and 19 severe infection (Group C). Significantly higher PCT-1 levels were found in group C (0.24 ng/mL) vs. group A (0.16 ng/mL), and PCT-2 in group C (1.2 ng/mL) vs. A (0.17 ng/mL), and in C vs. B (0.2 ng/mL). Chemokine concentrations (I-TAC-1, IP-10-1, IP-10-2) were significantly lower in Group A vs. B+C; I-TAC 1: 48.64 vs. 70.99 pg/mL, p = 0.03; IP-10 1: 59.95 vs. 96.84 pg/mL, p = 0.04; and IP-10 2: 102.40 vs. 149.39 pg/mL, p = 0.05. The selected pro-inflammatory chemokines I-TAC and IP10 might help to distinguish cancer patients with febrile neutropenia with the highest risk of infection. Although procalcitonin could serve as a marker of a high risk of infection, its delayed response diminishes its usefulness.
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Goren K, Monsour A, Stallwood E, Offringa M, Butcher NJ. Pediatric core outcome sets had deficiencies and lacked child and family input: A methodological review. J Clin Epidemiol 2022; 155:13-21. [PMID: 36528231 DOI: 10.1016/j.jclinepi.2022.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 10/31/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The Core Outcome Set-STAndards for Development (COS-STAD), published in 2017, contains 11 standards (12 criteria) describing minimum design criteria for core outcome set (COS) development. We aimed to identify and appraise all pediatric COS published prior to COS-STAD, and assess methods of child and family involvement in their development. STUDY DESIGN AND SETTING This methodological review included documents that described the development of pediatric COS up to and including 2017. Reviewers independently assessed each COS against COS-STAD criteria, and methods of involvement were synthesized. RESULTS A total of 56 pediatric COS were identified, meeting a median of five COS-STAD criteria. Nearly all met criteria on COS scope specification for setting, health condition, and population; 41% met criteria for intervention. Standards were more often met for the involvement of researchers/health professionals (64%) than for patients or their representatives (29%). Few met standards for achieving COS consensus (4-23%). Methods of child and family engagement varied and were limited. CONCLUSION A large proportion of pediatric COS developed prior to COS-STAD recommendations show gaps in design methodology. Updated and newly developed pediatric COS would benefit from the inclusion of the child and family voice, implementing a priori criteria for COS consensus, and clear reporting.
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Affiliation(s)
- Katherine Goren
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Andrea Monsour
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Emma Stallwood
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Neonatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nancy J Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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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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Leardini D, Muratore E, Abram N, Baccelli F, Belotti T, Prete A, Gori D, Masetti R. Effectiveness of Quinolone Prophylaxis in Pediatric Acute Leukemia and Hematopoietic Stem Cell Transplantation: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2022; 9:ofac594. [PMID: 36504701 PMCID: PMC9728521 DOI: 10.1093/ofid/ofac594] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
The effectiveness of quinolone prophylaxis in high-risk hematological pediatric patients is controversial. A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including studies that involved children and young adults undergoing chemotherapy for acute leukemia or hematopoietic stem cell transplantation (HSCT) who received quinolone prophylaxis compared with no prophylaxis. A meta-analysis was performed on bloodstream infections and neutropenic fever. Data regarding the impact of prophylaxis on overall survival, antibiotic exposure, antibiotic-related adverse effects, antibiotic resistance, Clostridium difficile infections, fungal infections, length of hospitalization, and costs were reviewed in the descriptive analysis. Sixteen studies were included in the qualitative analysis, and 10 of them met the criteria for quantitative analysis. Quinolone prophylaxis was effective in reducing the rate of bloodstream infections and neutropenic fever in pediatric acute leukemia compared with no prophylaxis, but it had no significant effect in HSCT recipients. Prophylaxis was associated with a higher rate of bacterial resistance to fluoroquinolones and higher antibiotic exposure.
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Affiliation(s)
| | | | - Nicoletta Abram
- Pediatric Oncology and Hematology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Baccelli
- Correspondence: F. Baccelli, MD, Pediatric Oncology and Hematology Unit “Lalla Seràgnoli,” Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Ospedale Policlinico S. Orsola-Malpighi, Via Massarenti 11, 40138 Bologna, Italy ()
| | - Tamara Belotti
- Pediatric Oncology and Hematology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Arcangelo Prete
- Pediatric Oncology and Hematology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Davide Gori
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
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Lei R, Shen Q, Yang B, Hou T, Liu H, Luo X, Li Y, Zhang J, Norris SL, Chen Y. Core Outcome Sets in Child Health: A Systematic Review. JAMA Pediatr 2022; 176:1131-1141. [PMID: 36094597 DOI: 10.1001/jamapediatrics.2022.3181] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Developing core outcome sets is essential to ensure that results of clinical trials are comparable and useful. A number of core outcome sets in pediatrics have been published, but a comprehensive in-depth understanding of core outcome sets in this field is lacking. OBJECTIVE To systematically identify core outcome sets in child health, collate the diseases to which core outcome sets have been applied, describe the methods used for development and stakeholder participation, and evaluate the methodological quality of existing core outcome sets. EVIDENCE REVIEW MEDLINE, SCOPUS, Cochrane Library, and CINAHL were searched using relevant search terms, such as clinical trials, core outcome, and children, along with relevant websites, such as Core Outcome Measures in Effectiveness Trials (COMET). Four researchers worked in teams of 2, performed literature screening and data extraction, and evaluated the methodological quality of core outcome sets using the Core Outcome Set-Standards for Development (COS-STAD). FINDINGS A total of 77 pediatric core outcome sets were identified, mainly developed by organizations or researchers in Europe, North America, and Australia and mostly from the UK (22 [29%]) and the US (22 [29%]). A total of 77 conditions were addressed; the most frequent International Classification of Diseases, 11th Revision category was diseases of the digestive system (14 [18%]). Most of the outcomes in pediatric core outcome sets were unordered (34 [44%]) or presented in custom classifications (29 [38%]). Core outcome sets used 1 or more of 8 development methods; the most frequent combination of methods was systematic review/literature review/scoping review, together with the Delphi approach and consensus for decision-making (10 [14%]). Among the 6 main types of stakeholders, clinical experts were the most frequently involved (74 [100%]), while industry representatives were rarely involved (4 [5%]). Only 6 core outcome sets (8%) met the 12 criteria of COS-STAD. CONCLUSIONS AND RELEVANCE Future quality of pediatric core outcome sets should be improved based on the standards proposed by the COMET initiative, while core outcome sets methodology and reporting standards should be extended to pediatric populations to help improve the quality of core outcome sets in child health. In addition, the COMET outcome taxonomy should also add items applicable to children.
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Affiliation(s)
- Ruobing Lei
- Chevidence Lab of Child and Adolescent Health, Children's Hospital of Chongqing Medical University, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Quan Shen
- Chevidence Lab of Child and Adolescent Health, Children's Hospital of Chongqing Medical University, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Bo Yang
- Shapingba District Center for Disease Control and Prevention of Chongqing, Chongqing, China
| | - Tianchun Hou
- Chevidence Lab of Child and Adolescent Health, Children's Hospital of Chongqing Medical University, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Hui Liu
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Xufei Luo
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Yuehuan Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junhua Zhang
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | | | - Yaolong Chen
- Chevidence Lab of Child and Adolescent Health, Children's Hospital of Chongqing Medical University, Chongqing, China.,Research Unit of Evidence-Based Evaluation and Guidelines, Chinese Academy of Medical Sciences, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,WHO Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou, China
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10
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Harbottle V, Arnott B, Gale C, Rowen E, Kolehmainen N. Identifying common health indicators from paediatric core outcome sets: a systematic review with narrative synthesis using the WHO International Classification of Functioning, Health and Disability. BMJ Paediatr Open 2022; 6:e001537. [PMID: 36645779 PMCID: PMC9621176 DOI: 10.1136/bmjpo-2022-001537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/19/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Indicators of child health have the potential to inform societal conversations, decision-making and prioritisation. Paediatric core outcome sets are an increasingly common way of identifying a minimum set of outcomes for trials within clinical groups. Exploring commonality across existing sets may give insight into universally important and inclusive child health indicators. METHODS A search of the Core Outcome Measures in Effectiveness Trial register from 2008 to 2022 was carried out. Eligible articles were those reporting on core outcome sets focused on children and young people aged 0-18 years old. The International Classification of Functioning, Disability and Health (ICF) was used as a framework to categorise extracted outcomes. Information about the involvement of children, young people and their families in the development of sets was also extracted. RESULTS 206 articles were identified, of which 36 were included. 441 unique outcomes were extracted, mapping to 22 outcome clusters present across multiple sets. Medical diagnostic outcomes were the biggest cluster, followed by pain, communication and social interaction, mobility, self-care and school. Children and young people's views were under-represented across core outcome sets, with only 36% of reviewed studies including them at any stage of development. CONCLUSIONS Existing paediatric core outcome sets show overlap in key outcomes, suggesting the potential for generic child health measurement frameworks. It is unclear whether existing sets best reflect health dimensions important to children and young people, and there is a need for better child and young person involvement in health indicator development to address this.
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Affiliation(s)
- Victoria Harbottle
- Rehabilitation Department, Great North Children's Hospital, Newcastle Upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Bronia Arnott
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Chris Gale
- Academic Neonatal Medicine, Imperial College London, London, UK
| | - Elizabeth Rowen
- Rehabilitation Department, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Niina Kolehmainen
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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11
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Koenig C, Kuehni CE, Bodmer N, Agyeman PKA, Ansari M, Roessler J, von der Weid NX, Ammann RA. Time to antibiotics is unrelated to outcome in pediatric patients with fever in neutropenia presenting without severe disease during chemotherapy for cancer. Sci Rep 2022; 12:14028. [PMID: 35982121 PMCID: PMC9388602 DOI: 10.1038/s41598-022-18168-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022] Open
Abstract
Fever in neutropenia (FN) remains an unavoidable, potentially lethal complication of chemotherapy. Timely administration of empirical broad-spectrum intravenous antibiotics has become standard of care. But the impact of time to antibiotics (TTA), the lag period between recognition of fever or arrival at the hospital to start of antibiotics, remains unclear. Here we aimed to analyze the association between TTA and safety relevant events (SRE) in data from a prospective multicenter study. We analyzed the association between time from recognition of fever to start of antibiotics (TTA) and SRE (death, admission to intensive care unit, severe sepsis and bacteremia) with three-level mixed logistic regression. We adjusted for possible triage bias using a propensity score and stratified the analysis by severity of disease at presentation with FN. We analyzed 266 FN episodes, including 53 (20%) with SRE, reported in 140 of 269 patients recruited from April 2016 to August 2018. TTA (median, 120 min; interquartile range, 49-180 min) was not associated with SRE, with a trend for less SREs in episodes with longer TTA. Analyses applying the propensity score suggested a relevant triage bias. Only in patients with severe disease at presentation there was a trend for an association of longer TTA with more SRE. In conclusion, TTA was unrelated to poor clinical outcome in pediatric patients with FN presenting without severe disease. We saw strong evidence for triage bias which could only be partially adjusted.
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Affiliation(s)
- Christa Koenig
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nicole Bodmer
- Pediatric Oncology, Kinderspital Zürich, University of Zürich, Zurich, Switzerland
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc Ansari
- Pediatric Hematology/Oncology, Department of Women, Child and Adolescent, University Hospital of Geneva, Geneva, Switzerland.,Department of Pediatrics, Gynecology, and Obstetrics, Cansearch Research Platform of Pediatric Oncology and Hematology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jochen Roessler
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Nicolas X von der Weid
- Division of Pediatric Hematology and Oncology, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland A Ammann
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.,Kinderaerzte KurWerk, Burgdorf, Switzerland
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12
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Haeusler GM, Garnham AL, Li‐Wai‐Suen CSN, Clark JE, Babl FE, Allaway Z, Slavin MA, Mechinaud F, Smyth GK, Phillips B, Thursky KA, Pellegrini M, Doerflinger M. Blood transcriptomics identifies immune signatures indicative of infectious complications in childhood cancer patients with febrile neutropenia. Clin Transl Immunology 2022; 11:e1383. [PMID: 35602885 PMCID: PMC9113042 DOI: 10.1002/cti2.1383] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/03/2022] [Accepted: 03/10/2022] [Indexed: 12/13/2022] Open
Abstract
Objectives Febrile neutropenia (FN) is a major cause of treatment disruption and unplanned hospitalization in childhood cancer patients. This study investigated the transcriptome of peripheral blood mononuclear cells (PBMCs) in children with cancer and FN to identify potential predictors of serious infection. Methods Whole-genome transcriptional profiling was conducted on PBMCs collected during episodes of FN in children with cancer at presentation to the hospital (Day 1; n = 73) and within 8-24 h (Day 2; n = 28) after admission. Differentially expressed genes as well as gene pathways that correlated with clinical outcomes were defined for different infectious outcomes. Results Global differences in gene expression associated with specific immune responses in children with FN and documented infection, compared to episodes without documented infection, were identified at admission. These differences resolved over the subsequent 8-24 h. Distinct gene signatures specific for bacteraemia were identified both at admission and on Day 2. Differences in gene signatures between episodes with bacteraemia and episodes with bacterial infection, viral infection and clinically defined infection were also observed. Only subtle differences in gene expression profiles between non-bloodstream bacterial and viral infections were identified. Conclusion Blood transcriptome immune profiling analysis during FN episodes may inform monitoring and aid in defining adequate treatment for different infectious aetiologies in children with cancer.
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious DiseasesPeter MacCallum Cancer CentreMelbourneVICAustralia,NHMRC National Centre for Infections in CancerSir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVICAustralia,Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVICAustralia,The Victorian Paediatric Integrated Cancer ServiceVictoria State GovernmentMelbourneVICAustralia,Infection Diseases UnitDepartment of General MedicineRoyal Children's HospitalMelbourneVICAustralia
| | - Alexandra L Garnham
- Walter and Eliza Hall Institute for Medical ResearchParkvilleVICAustralia,Department of Medical BiologyThe University of MelbourneMelbourneVICAustralia
| | - Connie SN Li‐Wai‐Suen
- Walter and Eliza Hall Institute for Medical ResearchParkvilleVICAustralia,Department of Medical BiologyThe University of MelbourneMelbourneVICAustralia
| | - Julia E Clark
- Queensland Children's HospitalChild Health Research CentreThe University of QueenslandBrisbaneQLDAustralia
| | - Franz E Babl
- Department of Emergency MedicineRoyal Children's HospitalMelbourneVICAustralia,Murdoch Children's Research InstitutePaediatric Research in Emergency Departments International Collaborative (PREDICT)MelbourneVICAustralia,Murdoch Children's Research InstituteMelbourneVICAustralia,Department of PaediatricsFaculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneMelbourneVICAustralia
| | - Zoe Allaway
- Department of Infectious DiseasesPeter MacCallum Cancer CentreMelbourneVICAustralia,NHMRC National Centre for Infections in CancerSir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVICAustralia,Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVICAustralia
| | - Monica A Slavin
- Department of Infectious DiseasesPeter MacCallum Cancer CentreMelbourneVICAustralia,NHMRC National Centre for Infections in CancerSir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVICAustralia,Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVICAustralia,Infection Diseases UnitDepartment of General MedicineRoyal Children's HospitalMelbourneVICAustralia,Victorian Infectious Diseases ServiceThe Peter Doherty Institute for Infection and ImmunityMelbourneVICAustralia
| | - Francoise Mechinaud
- Children's Cancer CentreThe Royal Children's HospitalMelbourneVICAustralia,Unité d'Hématologie Immunologie PédiatriqueHopital Robert DebréAPHP Nord Université de ParisParisFrance
| | - Gordon K Smyth
- Walter and Eliza Hall Institute for Medical ResearchParkvilleVICAustralia,School of Mathematics and StatisticsUniversity of MelbourneMelbourneVICAustralia
| | - Bob Phillips
- Leeds Children's HospitalLeeds General InfirmaryLeedsUK
| | - Karin A Thursky
- Department of Infectious DiseasesPeter MacCallum Cancer CentreMelbourneVICAustralia,NHMRC National Centre for Infections in CancerSir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVICAustralia,Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVICAustralia,Department of Infectious DiseasesNational Centre for Antimicrobial StewardshipUniversity of MelbourneMelbourneVICAustralia
| | - Marc Pellegrini
- NHMRC National Centre for Infections in CancerSir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVICAustralia,Walter and Eliza Hall Institute for Medical ResearchParkvilleVICAustralia,Department of Medical BiologyThe University of MelbourneMelbourneVICAustralia
| | - Marcel Doerflinger
- Walter and Eliza Hall Institute for Medical ResearchParkvilleVICAustralia,Department of Medical BiologyThe University of MelbourneMelbourneVICAustralia
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13
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Long E, Babl FE, Phillips N, Craig S, Zhang M, Kochar A, McCaskill M, Borland ML, Slavin MA, Phillips R, Lourenco RDA, Michinaud F, Thursky KA, Haeusler G. Prevalence and predictors of poor outcome in children with febrile neutropaenia presenting to the emergency department. Emerg Med Australas 2022; 34:786-793. [PMID: 35419955 DOI: 10.1111/1742-6723.13978] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/20/2022] [Accepted: 03/27/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Children with acquired neutropaenia due to cancer chemotherapy are at high risk of severe infection. The present study aims to describe the prevalence and predictors of poor outcomes in children with febrile neutropaenia (FN). METHODS This is a multicentre, prospective observational study in tertiary Australian EDs. Cancer patients with FN were included. Fever was defined as a single temperature ≥38°C, and neutropaenia was defined as an absolute neutrophil count <1000/mm3 . The primary outcome was the ICU admission for organ support therapy (inotropic support, mechanical ventilation, renal replacement therapy, extracorporeal life support). Secondary outcomes were: ICU admission, ICU length of stay (LOS) ≥3 days, proven or probable bacterial infection, hospital LOS ≥7 days and 28-day mortality. Initial vital signs, biomarkers (including lactate) and clinical sepsis scores, including Systemic Inflammatory Response Syndrome, quick Sequential Organ Failure Assessment and quick Paediatric Logistic Organ Dysfunction-2 were evaluated as predictors of poor outcomes. RESULTS Between December 2016 and January 2018, 2124 episodes of fever in children with cancer were screened, 547 episodes in 334 children met inclusion criteria. Four episodes resulted in ICU admission for organ support therapy, nine episodes required ICU admission, ICU LOS was ≥3 days in four, hospital LOS was ≥7 days in 153 and two patients died within 28 days. Vital signs, blood tests and clinical sepsis scores, including Systemic Inflammatory Response Syndrome, quick Sequential Organ Failure Assessment and quick Paediatric Logistic Organ Dysfunction-2, performed poorly as predictors of these outcomes (area under the receiver operating characteristic curve <0.6). CONCLUSIONS Very few patients with FN required ICU-level care. Vital signs, biomarkers and clinical sepsis scores for the prediction of poor outcomes are of limited utility in children with FN.
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Simon Craig
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Monash Medical Centre, Melbourne, Victoria, Australia.,Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Michael Zhang
- Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Amit Kochar
- Emergency Department, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Mary McCaskill
- Emergency Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Paediatrics and Emergency Medicine, School of Medicine, The University of Western Australia, Perth, Western Australia, 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, The University of Melbourne, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia.,Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Victorian Infectious Disease Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, UK.,Leed's Children's Hospital, Leeds General Infirmary, Leeds, UK
| | - Richard De A Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Francoise Michinaud
- Children's Cancer Centre, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Unité d'Hématologie Immunologie Pédiatrique, Hôpital Robert-Debré, APHP Nord Université de Paris, Paris, France
| | - 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, The University of Melbourne, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia.,Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Victorian Infectious Disease Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Gabrielle 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, The University of Melbourne, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia.,Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,The Victorian Paediatric Integrated Cancer Service, Victorian State Government, Melbourne, Victoria, Australia
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14
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Servidio AG, Simeone R, Zanon D, Barbi E, Maximova N. Levofloxacin Versus Ciprofloxacin-Based Prophylaxis during the Pre-Engraftment Phase in Allogeneic Hematopoietic Stem Cell Transplant Pediatric Recipients: A Single-Center Retrospective Matched Analysis. Antibiotics (Basel) 2021; 10:antibiotics10121523. [PMID: 34943735 PMCID: PMC8698935 DOI: 10.3390/antibiotics10121523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/04/2021] [Accepted: 12/11/2021] [Indexed: 11/20/2022] Open
Abstract
Infectious complications are the most common and significant cause of mortality and morbidity after allogeneic hematopoietic stem cell transplantation (HSCT). Antibacterial prophylaxis in pediatric cancer patients is a controversial issue. Our study compared the outcomes of levofloxacin versus ciprofloxacin prophylaxis in allogeneic HSCT pediatric recipients treated for hematological malignancies. A total of 120 patients received levofloxacin prophylaxis, and 60 patients received ciprofloxacin prophylaxis. Baseline characteristics such as age, gender, primary diagnosis, type of conditioning, donor type, stem cell source, and supportive care of the patients were similar, and duration of antibiotics prophylaxis was similar. Both prophylaxis regimens demonstrated the same efficacy on the risk of febrile neutropenia and severe complications such as sepsis, the same rate of overall mortality, hospital readmission, and length of hospital stay. Levofloxacin prophylaxis was associated with significantly lower cumulative antibiotic exposure. The median of Gram-positive infection-related antibiotic days was 10 days in the levofloxacin group versus 25 days in the ciprofloxacin group (p < 0.0001). The median of Gram-negative infection-related antibiotics was 10 days in the levofloxacin group compared with 20 days in the ciprofloxacin group (p < 0.0001). The number of days with body temperature ≥38 °C was significantly less in the levofloxacin group (p < 0.001).
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Affiliation(s)
- Alessia G. Servidio
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Piazzale Europa 1, 34127 Trieste, Italy; (A.G.S.); (E.B.)
| | - Roberto Simeone
- Department of Transfusion Medicine, ASUGI, Piazza dell’Ospitale 1, 34125 Trieste, Italy;
| | - Davide Zanon
- Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Via dell’Istria 65/1, 34137 Trieste, Italy;
| | - Egidio Barbi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Piazzale Europa 1, 34127 Trieste, Italy; (A.G.S.); (E.B.)
- Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Via dell’Istria 65/1, 34137 Trieste, Italy;
| | - Natalia Maximova
- Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Via dell’Istria 65/1, 34137 Trieste, Italy;
- Correspondence: ; Tel.: +39-040-3785276 (ext. 565); Fax: +39-040-3785494
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15
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Lavieri L, Koenig C, Bodmer N, Agyeman PKA, Scheinemann K, Ansari M, Roessler J, Ammann RA. Predicting fever in neutropenia with safety-relevant events in children undergoing chemotherapy for cancer: The prospective multicenter SPOG 2015 FN Definition Study. Pediatr Blood Cancer 2021; 68:e29253. [PMID: 34310027 DOI: 10.1002/pbc.29253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/11/2021] [Accepted: 07/12/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Fever in neutropenia (FN) remains a frequent complication in pediatric patients undergoing chemotherapy for cancer. Preventive strategies, like primary antibiotic prophylaxis, need to be evidence-based. PROCEDURE Data on pediatric patients with any malignancy from the prospective multicenter SPOG 2015 FN Definition Study (NCT02324231) were analyzed. A score predicting the risk to develop FN with safety-relevant events (SRE; bacteremia, severe sepsis, intensive care unit admission, death) was developed using multivariate mixed Poisson regression. Its predictive performance was assessed by internal cross-validation and compared with the performance of published rules. RESULTS In 238 patients, 318 FN episodes were recorded, including 53 (17%) with bacteremia and 68 (21%) with SRE. The risk-prediction score used three variables: chemotherapy intensity, defined according to the expected duration of severe neutropenia, time since diagnosis, and type of malignancy. Its cross-validated performance, assessed by the time needed to cover (TNC) one event, exceeded the performance of published rules. A clinically useful score threshold of ≥11 resulted in 2.3% time at risk and 4.1 months TNC. Using external information on efficacy and timing of intermittent antibiotic prophylaxis, 4.3 months of prophylaxis were needed to prevent one FN with bacteremia, and 5.2 months to prevent one FN with SRE, using a threshold of ≥11. CONCLUSIONS This score, based on three routinely accessible characteristics, accurately identifies pediatric patients at risk to develop FN with SRE during chemotherapy. The score can help to design clinical decision rules on targeted primary antibiotic prophylaxis and corresponding efficacy studies.
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Affiliation(s)
- Luana Lavieri
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christa Koenig
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Bodmer
- Pediatric Oncology, University Children's Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katrin Scheinemann
- Pediatric Hematology/Oncology, Department of Pediatrics, Kantonsspital Aarau, Aarau, Switzerland.,University of Basel, Basel, Switzerland.,Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
| | - Marc Ansari
- Pediatric Hematology/Oncology, Department of Women, Child and Adolescent, University Hospital of Geneva, Geneva, Switzerland.,Department of Pediatrics, Gynecology, and Obstetrics, Cansearch Research Platform of Pediatric Oncology and Hematology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jochen Roessler
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roland A Ammann
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Kinderaerzte KurWerk, Burgdorf, Switzerland
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16
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Schlenker L, Manworren RCB. Timing of Pegfilgrastim: Association with Febrile Neutropenia in a Pediatric Solid and CNS Tumor Population. J Pediatr Oncol Nurs 2021; 38:375-384. [PMID: 34402328 DOI: 10.1177/10434542211037729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: While recommended timing of pegfilgrastim administration is ≥24 h after chemotherapy, patient barriers to next day administration, available adult evidence, and pharmacokinetic data have led to earlier administration in some pediatric patients with solid and central nervous system tumors. The purpose of this study was to compare patient outcomes by timing of pegfilgrastim after chemotherapy. Methods: A retrospective chart review examined timing of 932 pegfilgrastim administrations to 182 patients, 0-29 years of age. The primary outcome was febrile neutropenia (FN); the secondary outcome was neutropenic delays (ND) ≥7 days to next chemotherapy cycle. To account for multiple pegfilgrastim administrations per patient, a generalized mixed model was used with a logit link for the dichotomous outcomes (FN & ND), timing as the dichotomous independent variable, and random effect for patient. Results: FN occurred in 196 of 916 cycles (21.4%); and ND in 19 of 805 cycles (2.4%). The fixed effect of pegfilgrastim administration < or ≥24 h after chemotherapy was not significant, p = .50; however, earlier or later than 20 h was significant, p = .005. FN odds were significantly higher when pegfilgrastim was given <20 h (OR 1.78, 95% CI: 1.19-2.65) after chemotherapy, which may be attributable to differences in chemotherapy toxicity regardless of pegfilgrastim timing. Discussion: While attempts should be made to administer pegfilgrastim ≥24 h after chemotherapy, if barriers exist, modified timing based on individual patient characteristics should be considered. Prospective randomized trials are needed to identify lower risk patients for early pegfilgrastim administration.
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Affiliation(s)
- Laura Schlenker
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Renee C B Manworren
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Pediatrics, 12244Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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17
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Gonzalez ML, Aristizabal P, Loera-Reyna A, Torres D, Ornelas-Sánchez M, Nuño-Vázquez L, Aguilera M, Sánchez A, Romano M, Rivera-Gómez R, Relyea G, Friedrich P, Caniza MA. The Golden Hour: Sustainability and Clinical Outcomes of Adequate Time to Antibiotic Administration in Children with Cancer and Febrile Neutropenia in Northwestern Mexico. JCO Glob Oncol 2021; 7:659-670. [PMID: 33974443 PMCID: PMC8162497 DOI: 10.1200/go.20.00578] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Time to antibiotic administration (TTA) is a commonly used standard of care in pediatric cancer settings in high-income countries. Effective interventions to improve outcomes in cancer patients with febrile neutropenia (FN) often address timely and appropriate antibiotic administration. We assessed the effectiveness of a locally adapted multimodal strategy in decreasing TTA in a resource-constrained pediatric cancer center in Mexico. METHODS We conducted a prospective observational study between January 2014 and April 2019. A three-phase (phase I: execution, phase II: consolidation, phase III: sustainability) multimodal improvement strategy that combined system change, FN guideline development, education, auditing and monitoring, mentoring, and dissemination was implemented to decrease TTA in inpatient and ambulatory areas. Sustainability factors were measured by using a validated tool during phases I and III. RESULTS Our population included 105 children with cancer with 204 FN events. The baseline assessment revealed that only 50% of patients received antibiotics within 60 minutes of prescription (median time: inpatient, 75 minutes; ambulatory, 65 minutes). After implementing our improvement strategy, the percentage of patients receiving antibiotics within 60 minutes of prescription increased to 88%. We significantly decreased median TTA in both clinical areas during the three phases of the study. In phase III (sustainability), the median TTA was 40 minutes (P = .023) in the inpatient area and 30 minutes (P = .012) in the ambulatory area. The proportion of patients with sepsis decreased from 30% (baseline) to 5% (phase III) (P = .001). CONCLUSION Our results demonstrate that locally adapted multimodal interventions can reduce TTA in resource-constrained settings. Mentoring and dissemination were novel components of the multimodal strategy to improve FN-associated clinical outcomes. Improving local infrastructure, ongoing monitoring systems, and leadership engagement have been key factors to achieving sustainability during the 5-year period.
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Affiliation(s)
- Miriam L Gonzalez
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Paula Aristizabal
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of California San Diego, La Jolla, CA.,Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital San Diego, San Diego, CA.,Population Sciences, Disparities and Community Engagement, Moores Cancer Center, University of California San Diego, La Jolla, CA
| | - Adriana Loera-Reyna
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Dara Torres
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Mario Ornelas-Sánchez
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Laura Nuño-Vázquez
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Marco Aguilera
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Alicia Sánchez
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Mitzy Romano
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - Rebeca Rivera-Gómez
- Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico
| | - George Relyea
- School of Public Health, University of Memphis, Memphis, TN
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Miguela A Caniza
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN.,Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN
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18
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Pugliese M, Tingley K, Chow A, Pallone N, Smith M, Chakraborty P, Geraghty MT, Irwin JK, Mitchell JJ, Stockler S, Nicholls SG, Offringa M, Rahman A, Tessier LA, Butcher NJ, Iverson R, Lamoureux M, Clifford TJ, Hutton B, Paik K, Tao J, Skidmore B, Coyle D, Duddy K, Dyack S, Greenberg CR, Jain Ghai S, Karp N, Korngut L, Kronick J, MacKenzie A, MacKenzie J, Maranda B, Potter M, Prasad C, Schulze A, Sparkes R, Taljaard M, Trakadis Y, Walia J, Potter BK. Core Outcome Sets for Medium-Chain Acyl-CoA Dehydrogenase Deficiency and Phenylketonuria. Pediatrics 2021; 148:peds.2020-037747. [PMID: 34266901 DOI: 10.1542/peds.2020-037747] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Evidence to guide treatment of pediatric medium-chain acyl-coenzyme A dehydrogenase (MCAD) deficiency and phenylketonuria (PKU) is fragmented because of large variability in outcome selection and measurement. Our goal was to develop core outcome sets (COSs) for these diseases to facilitate meaningful future evidence generation and enhance the capacity to compare and synthesize findings across studies. METHODS Parents and/or caregivers, health professionals, and health policy advisors completed a Delphi survey and participated in a consensus workshop to select core outcomes from candidate lists of outcomes for MCAD deficiency and PKU. Delphi participants rated the importance of outcomes on a nine-point scale (1-3: not important, 4-6: important but not critical, 7-9: critical). Candidate outcomes were progressively narrowed down over 3 survey rounds. At the workshop, participants evaluated the remaining candidate outcomes using an adapted nominal technique, open discussion, and voting. After the workshop, we finalized the COSs and recommended measurement instruments for each outcome. RESULTS There were 85, 61, and 53 participants across 3 Delphi rounds, respectively. The candidate core outcome lists were narrowed down to 20 outcomes per disease to be discussed at the consensus workshop. Voting by 18 workshop participants led to COSs composed of 8 and 9 outcomes for MCAD deficiency and PKU, respectively, with measurement recommendations. CONCLUSIONS These are the first known pediatric COSs for MCAD deficiency and PKU. Adoption in future studies will help to ensure best use of limited research resources to ultimately improve care for children with these rare diseases.
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Affiliation(s)
- Michael Pugliese
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Kylie Tingley
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Andrea Chow
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Nicole Pallone
- Patient partner, Canadian Organization for Rare Disorders, Toronto, Canada
| | | | - Pranesh Chakraborty
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada.,Divisions of Medical Genetics and Pediatric Endocrinology, Montreal Children's Hospital, McGill University Health Center, Montreal, Canada
| | - Michael T Geraghty
- Divisions of Medical Genetics and Pediatric Endocrinology, Montreal Children's Hospital, McGill University Health Center, Montreal, Canada
| | - Julie K Irwin
- Biochemical Diseases, British Columbia Children's Hospital, Vancouver, Canada
| | - John J Mitchell
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sylvia Stockler
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Stuart G Nicholls
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Martin Offringa
- Department of Psychiatry, University of Toronto, Toronto, Canada.,Department of Pediatrics, Dalhousie University, Halifax, Canada
| | - Alvi Rahman
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Laure A Tessier
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Nancy J Butcher
- Department of Pediatrics, Dalhousie University, Halifax, Canada.,Patient partner, Canadian Phenylketonuria & Allied Disorders Inc, Toronto, Canada
| | - Ryan Iverson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Monica Lamoureux
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Tammy J Clifford
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Karen Paik
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Jessica Tao
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Becky Skidmore
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Kathleen Duddy
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Sarah Dyack
- Department of Medical Genetics, University of Alberta, Edmonton, Canada
| | | | - Shailly Jain Ghai
- Departments of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Natalya Karp
- Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Canada
| | - Lawrence Korngut
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Jonathan Kronick
- Department of Psychiatry, University of Toronto, Toronto, Canada.,Department of Pediatrics, Dalhousie University, Halifax, Canada
| | - Alex MacKenzie
- Division of Metabolics, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | | | - Bruno Maranda
- Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Murray Potter
- Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Canada
| | - Chitra Prasad
- Departments of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Andreas Schulze
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Rebecca Sparkes
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Yannis Trakadis
- Medical Genetics, and Pediatrics, University of Calgary, Calgary, Canada
| | - Jagdeep Walia
- Department of Human Genetics, McGill University, Montreal, Canada
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19
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Ockfen S, Egle L, Sauter K, Haber M, Becker SL, Wagenpfeil G, Graf N, Simon A. Meropenem Use in Pediatric Oncology - Audit on Indication, Appropriateness and Consumption Comparing Patient Derived and Pharmacy Dispensing Data. KLINISCHE PADIATRIE 2021; 233:278-285. [PMID: 34261135 DOI: 10.1055/a-1481-8905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Meropenem is an important second- or third-line antibiotic in pediatric cancer patients with febrile neutropenia (FN). Concise utilization data of meropenem in this setting is limited. It remains unclear how drug dispensing data from the hospital pharmacy correlate with data derived from patients' files. METHODS Retrospective audit of meropenem-consumption in a University-affiliated pediatric oncology center in days of therapy (DOT)/100 inpatient days. The individual indication for meropenem was critically reviewed. The real consumption (in g/100 inpatient days) was compared with the drug amounts dispensed by the hospital pharmacy (in gram and in defined daily doses (DDD)/100 inpatient days). All patients receiving at least one dose of meropenem from 1st of April 2016 until the 30th of June 2018 were included. RESULT Of 235 consecutive patients, 45 (19%) received meropenem, comprising 57 FN events. The probability of receiving at least one dose of meropenem was significantly higher in patients with ALL, AML, NHL and certain CNS tumors. Preceding the use of meropenem, only 5% of patients were known to be colonized with multidrug-resistant Gram-negative pathogens. Meropenem was administered as first-line treatment in 26% of all meropenem cycles, in 74% of all FN events with meropenem, Piperacillin-Tazobactam was used for initial treatment. In 5 of 57 FN events (8.8%), initial blood cultures yielded a Gram-negative pathogen. Concerning definite treatment, appropriate alternatives to meropenem with a smaller spectrum of activity would have been available in 4 cases, but a de-escalation was not performed. The median length of therapy in the meropenem group was 6 days, the corresponding median for days of therapy (DOT) was 12 days. This corresponds with combination therapy in 56% of all meropenem treatments, mostly with teicoplanin. On average, drug dispensing data from the hospital pharmacy were 1.53 times higher than real use (relying on patients' data) without a significant correlation. A higher Case-mix Index positively correlated with meropenem-consumption. CONCLUSION The use of meropenem should become a target of antibiotic stewardship programs in order to restrict its use to certain indications and preserve its outstanding role as second- or third-line antibiotic in this vulnerable population. Irrespective of the metrics used (g or DDD/100 inpatient days), pharmacy dispensing data do not accurately depict real patient-derived data concerning meropenem use in pediatric cancer patients.
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Affiliation(s)
- Svenja Ockfen
- Pediatric Hematology and Oncology, Children's Hospital Medical Center, Children's Hospital Medical Center, Saarland University Hospital, Homburg, Germany
| | - Leonie Egle
- Pediatric Hematology and Oncology, Children's Hospital Medical Center, Children's Hospital Medical Center, Saarland University Hospital, Homburg, Germany
| | - Katharina Sauter
- Paediatric Hematology and Oncology, Children's Hospital Medical Center, Homburg, Germany
| | - Manfred Haber
- Director Hospital Pharmacy, Saarland University Hospital, Homburg/Saar, Homburg, Germany
| | - Sören L Becker
- Medical Microbiology and Hygiene, Saarland University Medical Center, Homburg, Germany
| | - Gudrun Wagenpfeil
- Saarland University, Campus Homburg, Institutes for Medical Biometry, Epidemiology and Medical Informatics (IMBEI), Homburg, Germany
| | - Norbert Graf
- Paediatric Hematology and Oncology, Children's Hospital Medical Center, Homburg, Germany
| | - Arne Simon
- Paediatric Hematology and Oncology, Children's Hospital Medical Center, Homburg, Germany
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20
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Doerflinger M, Haeusler GM, Li-Wai-Suen CSN, Clark JE, Slavin M, Babl FE, Allaway Z, Mechinaud F, Smyth GK, De Abreu Lourenco R, Phillips B, Pellegrini M, Thursky KA. Procalcitonin and Interleukin-10 May Assist in Early Prediction of Bacteraemia in Children With Cancer and Febrile Neutropenia. Front Immunol 2021; 12:641879. [PMID: 34093531 PMCID: PMC8173204 DOI: 10.3389/fimmu.2021.641879] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/27/2021] [Indexed: 12/23/2022] Open
Abstract
Objectives Febrile neutropenia (FN) causes treatment disruption and unplanned hospitalization in children with cancer. Serum biomarkers are infrequently used to stratify these patients into high or low risk for serious infection. This study investigated plasma abundance of cytokines in children with FN and their ability to predict bacteraemia. Methods Thirty-three plasma cytokines, C-reactive protein (CRP) and procalcitonin (PCT) were measured using ELISA assays in samples taken at FN presentation (n = 79) and within 8–24 h (Day 2; n = 31). Optimal thresholds for prediction of bacteraemia were identified and the predictive ability of biomarkers in addition to routinely available clinical variables was assessed. Results The median age of included FN episodes was 6.0 years and eight (10%) had a bacteraemia. On presentation, elevated PCT, IL-10 and Mip1-beta were significantly associated with bacteraemia, while CRP, IL-6 and IL-8 were not. The combination of PCT (≥0.425 ng/ml) and IL-10 (≥4.37 pg/ml) had a sensitivity of 100% (95% CI 68.8–100%) and specificity of 89% (95% CI 80.0–95.0%) for prediction of bacteraemia, correctly identifying all eight bacteraemia episodes and classifying 16 FN episodes as high-risk. There was limited additive benefit of incorporating clinical variables to this model. On Day 2, there was an 11-fold increase in PCT in episodes with a bacteraemia which was significantly higher than that observed in the non-bacteraemia episodes. Conclusion Elevated PCT and IL-10 accurately identified all bacteraemia episodes in our FN cohort and may enhance the early risk stratification process in this population. Prospective validation and implementation is required to determine the impact on health service utilisation.
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Affiliation(s)
- Marcel Doerflinger
- Infectious Diseases and Immune Defence Division, Walter and Eliza Hall Institute for Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Infection and Immunity Theme, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, VIC, Australia
| | - Connie S N Li-Wai-Suen
- Infectious Diseases and Immune Defence Division, Walter and Eliza Hall Institute for Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia
| | - Julia E Clark
- Queensland Children's Hospital, Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
| | - Monica Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.,Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Franz E Babl
- Infection and Immunity Theme, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Emergency Department, Royal Children's Hospital, Parkville, VIC, Australia.,Paediatric Emergency Medicine Centre of Research Excellence, ED Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Zoe Allaway
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, VIC, Australia
| | - Francoise Mechinaud
- Unité D'hématologie Immunologie Pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, Paris, France
| | - Gordon K Smyth
- Infectious Diseases and Immune Defence Division, Walter and Eliza Hall Institute for Medical Research, Parkville, VIC, Australia.,School of Mathematics and Statistics, The University of Melbourne, Melbourne, VIC, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, NSW, Australia
| | - Bob Phillips
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, United Kingdom
| | - Marc Pellegrini
- Infectious Diseases and Immune Defence Division, Walter and Eliza Hall Institute for Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, VIC, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
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21
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Morgan JE, Phillips B, Haeusler GM, Chisholm JC. Optimising Antimicrobial Selection and Duration in the Treatment of Febrile Neutropenia in Children. Infect Drug Resist 2021; 14:1283-1293. [PMID: 33833534 PMCID: PMC8019605 DOI: 10.2147/idr.s238567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/11/2021] [Indexed: 12/13/2022] Open
Abstract
Febrile neutropenia (FN) is a frequent complication of cancer treatment in children. Owing to the potential for overwhelming bacterial sepsis, the recognition and management of FN requires rapid implementation of evidenced-based management protocols. Treatment paradigms have progressed from hospitalisation with broad spectrum antibiotics for all patients, through to risk adapted approaches to management. Such risk adapted approaches aim to provide safe care through incorporating antimicrobial stewardship (AMS) principles such as implementation of comprehensive clinical pathways incorporating de-escalation strategies with the imperative to reduce hospital stay and antibiotic exposure where possible in order to improve patient experience, reduce costs and diminish the risk of nosocomial infection. This review summarises the principles of risk stratification in FN, the current key considerations for optimising empiric antimicrobial selection including knowledge of antimicrobial resistance patterns and emerging technologies for rapid diagnosis of specific infections and summarises existing evidence on time to treatment, investigations required and duration of treatment. To aid treating physicians we suggest the key features based on current evidence that should be part of any FN management guideline and highlight areas for future research. The focus is on treatment of bacterial infections although fungal and viral infections are also important in this patient group.
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Affiliation(s)
- Jessica E Morgan
- Centre for Reviews and Dissemination, University of York, Heslington, YO10 5DD, UK.,Department of Paediatric Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, Heslington, YO10 5DD, UK.,Department of Paediatric Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Gabrielle M Haeusler
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, 3010, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, 3010, Australia.,Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, 3168, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, 3052, Australia
| | - Julia C Chisholm
- Royal Marsden Hospital and Institute of Cancer Research, Sutton, SM2 5PT, UK
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22
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Haeusler GM, De Abreu Lourenco R, Clark H, Thursky KA, Slavin MA, Babl FE, Mechinaud F, Alvaro F, Clark J, Padhye B, Phillips M, Super L, Tapp H, Walwyn T, Ziegler D, Phillips R, Worth LJ. Diagnostic Yield of Initial and Consecutive Blood Cultures in Children With Cancer and Febrile Neutropenia. J Pediatric Infect Dis Soc 2021; 10:125-130. [PMID: 32267508 DOI: 10.1093/jpids/piaa029] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/30/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The timing and necessity of repeated blood cultures (BCs) in children with cancer and febrile neutropenia (FN) are unknown. We evaluated the diagnostic yield of BCs collected pre- and post-empiric FN antibiotics. METHODS Data collected prospectively from the Australian Predicting Infectious ComplicatioNs in Children with Cancer (PICNICC) study were used. Diagnostic yield was calculated as the number of FN episodes with a true bloodstream infection (BSI) detected divided by the number of FN episodes that had a BC taken. RESULTS A BSI was identified in 13% of 858 FN episodes. The diagnostic yield of pre-antibiotic BCs was higher than of post-antibiotic cultures (12.3% vs 4.4%, P < .001). Two-thirds of the post-antibiotic BSIs were associated with a new episode of fever or clinical instability, and only 2 new BSIs were identified after 48 hours of empiric antibiotics and persistent fever. A contaminated BC was identified more frequently in post-antibiotic cultures. CONCLUSIONS In the absence of new fever or clinical instability, BCs beyond 48 hours of persistent fever have limited yield. Opportunity exists to optimize BC collection in this population and reduce the burden of unnecessary tests on patients, healthcare workers, and hospitals.
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,National Health and Medical Research Council, National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Paediatric Integrated Cancer Service, Victoria State Government, Melbourne, Australia.,Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
| | | | - Hannah Clark
- Paediatric Integrated Cancer Service, Victoria State Government, Melbourne, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,National Health and Medical Research Council, National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.,NHMRC, National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia.,Victorian Infectious Diseases Service, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,National Health and Medical Research Council, National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.,Victorian Infectious Diseases Service, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - Francoise Mechinaud
- Unité d'hématologie immunologie pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, Paris, France
| | - Frank Alvaro
- Children's Cancer Department, John Hunter Children's Hospital, University of Newcastle, Newcastle, Australia
| | - Julia Clark
- Infection Management Service, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Bhavna Padhye
- Kid's Cancer Centre, Westmead Children's Hospital, Sydney, Australia
| | | | - Leanne Super
- Children's Cancer Centre, Monash Children's Hospital, Monash Health, Melbourne, Australia
| | - Heather Tapp
- Department of Oncology, Women's and Children's Hospital, Adelaide, Australia
| | - Thomas Walwyn
- Department of Oncology, Perth Children's Hospital, Perth, Australia
| | - David Ziegler
- Kid's Cancer Centre, Sydney Children's Hospital, Sydney, Australia
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,National Health and Medical Research Council, National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
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23
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McMullan BJ, Haeusler GM, Hall L, Cooley L, Stewardson AJ, Blyth CC, Jones CA, Konecny P, Babl FE, Mechinaud F, Thursky K. Aminoglycoside use in paediatric febrile neutropenia - Outcomes from a nationwide prospective cohort study. PLoS One 2020; 15:e0238787. [PMID: 32936822 PMCID: PMC7494114 DOI: 10.1371/journal.pone.0238787] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/22/2020] [Indexed: 11/18/2022] Open
Abstract
Aminoglycosides are commonly prescribed to children with febrile neutropenia (FN) but their impact on clinical outcomes is uncertain and extent of guideline compliance is unknown. We aimed to review aminoglycoside prescription and additional antibiotic prescribing, guideline compliance and outcomes for children with FN. We analysed data from the Australian Predicting Infectious ComplicatioNs in Children with Cancer (PICNICC) prospective multicentre cohort study, in children <18 years with FN between November 2016 and January 2018. Impact of aminoglycoside use in the first 12 hours of FN on composite unfavourable outcome of death, ICU admission, relapse of infection or late-onset sepsis was assessed using multivariable Cox regression. The study was conducted in Australia where antimicrobial resistance among gram negative organisms is relatively low. Data from 858 episodes of FN in 462 children from 8 centres were assessed, median age 5.8 years (IQR 3.5-10.8 years). Early empiric aminoglycosides were prescribed in 255 episodes (29.7%). Guideline non-compliance was common: in 46% (184/400) of eligible episodes, patients did not receive aminoglycosides, while aminoglycosides were prescribed in 9% (39/458) of guideline-ineligible episodes. Adjusted hazard of the composite unfavourable outcome was 3.81 times higher among patients prescribed empiric aminoglycosides than among those who weren't (95% confidence interval, 1.89-7.67), with no increased risk of unfavourable outcome in eligible patients who did not receive aminoglycosides. In a large paediatric FN cohort, aminoglycoside prescription was common and was often non-compliant with guidelines. There was no evidence for improved outcome with aminoglycosides, even in those who met guideline criteria, within a low-resistance setting. Empiric aminoglycoside prescription for children with FN requires urgent review in guidelines and in national practice.
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Affiliation(s)
- Brendan J. McMullan
- NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia
- Department of Immunology and Infectious Diseases, Sydney Children’s Hospital, Randwick, Sydney, NSW, Australia
- School of Women’s and Children’s Health, University of New South Wales, Sydney, NSW, Australia
- * E-mail:
| | - Gabrielle M. Haeusler
- NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- The Paediatric Integrated Cancer Service, Parkville, Victoria, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children’s Hospital, Parkville, Victoria, Australia
- Infection and Immunity Theme, The Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Lisa Hall
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - Louise Cooley
- Department of Microbiology and Infectious Diseases, Department of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Andrew J. Stewardson
- Department of Infectious Diseases, The Alfred and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Christopher C. Blyth
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- Department of Paediatric Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
- Department of Microbiology, PathWest Laboratory Medicine, QEII Medical Centre, Perth, Western Australia, Australia
| | - Cheryl A. Jones
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Sydney Children’s Hospital Network–The Children’s at Westmead, Westmead, NSW, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Pamela Konecny
- Department of Infectious Diseases, Immunology & Sexual Health, St George Hospital, Sydney, NSW, Australia
- St George & Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Franz E. Babl
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Department of Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
| | - Françoise Mechinaud
- Royal Children's Hospital, Parkville, Victoria, Australia
- Hôpital Robert Debré APHP Nord-Université de Paris, Paris, France
| | - Karin Thursky
- NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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Haeusler GM, Gaynor L, Teh B, Babl FE, Orme LM, Segal A, Mechinaud F, Bryant PA, Phillips B, Lourenco RDA, Slavin MA, Thursky KA. Home-based care of low-risk febrile neutropenia in children-an implementation study in a tertiary paediatric hospital. Support Care Cancer 2020; 29:1609-1617. [PMID: 32740894 DOI: 10.1007/s00520-020-05654-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 07/24/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Home-based management of low-risk febrile neutropenia (FN) is safe, improves quality of life and reduces healthcare expenditure. A formal low-risk paediatric program has not been implemented in Australia. We aimed to describe the implementation process and evaluate the clinical impact. METHOD This prospective study incorporated three phases: implementation, intervention and evaluation. A low-risk FN implementation toolkit was developed, including a care-pathway, patient information, home-based assessment and educational resources. The program had executive-level endorsement, a multidisciplinary committee and a nurse specialist. Children with cancer and low-risk FN were eligible to be transferred home with a nurse visiting daily after an overnight period of observation for intravenous antibiotics. Low-risk patients were identified using a validated decision rule, and suitability for home-based care was determined using disease, chemotherapy and patient-level criteria. Plan-Do-Study-Act methodology was used to evaluate clinical impact and safety. RESULTS Over 18 months, 292 children with FN were screened: 132 (45%) were low-risk and 63 (22%) were transferred to home-based care. Compared with pre-implementation there was a significant reduction in in-hospital median LOS (4.0 to 1.5 days, p < 0.001) and 291 in-hospital bed days were saved. Eight (13%) patients needed readmission and there were no adverse outcomes. A key barrier was timely screening of all patients and program improvements, including utilising the electronic medical record for patient identification, are planned. CONCLUSION This program significantly reduces in-hospital LOS for children with low-risk FN. Ongoing evaluation will inform sustainability, identify areas for improvement and support national scale-up of the program.
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia. .,University of Melbourne, Parkville, Victoria, Australia. .,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia. .,The Paediatric Integrated Cancer Service, Parkville, Victoria, Australia. .,Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia. .,Murdoch Children's Research Institute, Parkville, Victoria, Australia.
| | - Lynda Gaynor
- The Paediatric Integrated Cancer Service, Parkville, Victoria, Australia.,Hospital In The Home Department, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Benjamin Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Emergency Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Lisa M Orme
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Ahuva Segal
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Francoise Mechinaud
- Unité d'hématologie immunologie pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, Paris, France
| | - Penelope A Bryant
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Hospital In The Home Department, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, New South Wales, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, 3010, Australia.,Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, 3010, Australia.,Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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25
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39·0°C versus 38·5°C ear temperature as fever limit in children with neutropenia undergoing chemotherapy for cancer: a multicentre, cluster-randomised, multiple-crossover, non-inferiority trial. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:495-502. [DOI: 10.1016/s2352-4642(20)30092-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/24/2020] [Accepted: 03/24/2020] [Indexed: 02/01/2023]
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Management of children with fever and neutropenia: results of a survey in 51 pediatric cancer centers in Germany, Austria, and Switzerland. Infection 2020; 48:607-618. [PMID: 32524514 PMCID: PMC7395019 DOI: 10.1007/s15010-020-01462-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/02/2020] [Indexed: 12/19/2022]
Abstract
Purpose Investigation of the current practice of diagnostics and treatment in pediatric cancer patients with febrile neutropenia. Methods On behalf of the German Society for Pediatric Oncology and Hematology and the German Society for Pediatric Infectious Diseases, an Internet-based survey was conducted in 2016 concerning the management of febrile neutropenia in pediatric oncology centers (POC). This survey accompanied the release of the corresponding German guideline to document current practice before its implementation in clinical practice. Results In total, 51 POCs participated (response rate 73%; 43 from Germany, and 4 each from Austria and Switzerland). Identified targets for antimicrobial stewardship concerned blood culture diagnostics, documentation of the time to antibiotics, the use of empirical combination therapy, drug monitoring of aminoglycosides, the time to escalation in patients with persisting fever, minimal duration of IV treatment, sequential oral treatment in patients with persisting neutropenia, indication for and choice of empirical antifungal treatment, and the local availability of a pediatric infectious diseases consultation service. Conclusion This survey provides useful information for local antibiotic stewardship teams to improve the current practice referring to the corresponding national and international guidelines. Electronic supplementary material The online version of this article (10.1007/s15010-020-01462-z) contains supplementary material, which is available to authorized users.
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Haeusler GM, Phillips R, Slavin MA, Babl FE, De Abreu Lourenco R, Mechinaud F, Thursky KA. Re-evaluating and recalibrating predictors of bacterial infection in children with cancer and febrile neutropenia. EClinicalMedicine 2020; 23:100394. [PMID: 32637894 PMCID: PMC7329706 DOI: 10.1016/j.eclinm.2020.100394] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Numerous paediatric febrile neutropenia (FN) clinical decision rules (CDRs) have been derived. Validation studies show reduced performance in external settings. We evaluated the association between variables common across published FN CDRs and bacterial infection and recalibrated existing CDRs using these data. METHODS Prospective data from the Australian-PICNICC study which enrolled 858 FN episodes in children with cancer were used. Variables shown to be significant predictors of infection or adverse outcome in >1 CDR were analysed using multivariable logistic regression. Recalibration included re-evaluation of beta-coefficients (logistic model) or recursive-partition analysis (tree-based models). FINDINGS Twenty-five unique variables were identified across 17 FN CDRs. Fourteen were included in >1 CDR and 10 were analysed in our dataset. On univariate analysis, location, temperature, hypotension, rigors, severely unwell and decreasing platelets, white cell count, neutrophil count and monocyte count were significantly associated with bacterial infection. On multivariable analysis, decreasing platelets, increasing temperature and the appearance of being clinically unwell remained significantly associated. Five rules were recalibrated. Across all rules, recalibration increased the AUC-ROC and low-risk yield as compared to non-recalibrated data. For the SPOG-adverse event CDR, recalibration also increased sensitivity and specificity and external validation showed reproducibility. INTERPRETATION Degree of marrow suppression (low platelets), features of inflammation (temperature) and clinical judgement (severely unwell) have been consistently shown to predict infection in children with FN. Recalibration of existing CDRs is a novel way to improve diagnostic performance of CDRs and maintain relevance over time. FUNDING National Health and Medical Research Council Grant (APP1104527).
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- The Paediatric Integrated Cancer Service, Parkville, Victoria State Government, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Australia
- Murdoch Children's Research Institute, Parkville, Australia
- Corresponding author: Dr Gabrielle M. Haeusler, Department of Infectious Diseases, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Australia, 3000, P: +61 3 9656 5853 F: +61 3 9656 1185.
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, United Kingdom
| | - Monica A. Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute, Parkville, Australia
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Broadway, Australia
| | - Francoise Mechinaud
- Unité d'hématologie immunologie pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, France
| | - Karin A. Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
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Brack E, Wagner S, Stutz-Grunder E, Agyeman PKA, Ammann RA. Temperatures, diagnostics and treatment in pediatric cancer patients with fever in neutropenia, NCT01683370. Sci Data 2020; 7:156. [PMID: 32457478 PMCID: PMC7250883 DOI: 10.1038/s41597-020-0504-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/22/2020] [Indexed: 11/18/2022] Open
Abstract
In pediatric oncology, there is no evidence-based definition of the temperature limit defining fever (TLDF), which itself is essential for the definition of fever in chemotherapy-induced severe neutropenia (FN). Lowering the TLDF can increase the number of FN episodes diagnosed. This prospective, single center observational study collected data on all temperature measurements, complete blood counts (CBCs), and measures of diagnostics and therapy performed at and after FN diagnosis in pediatric oncology patients using a high standard TLDF (39 °C ear temperature). In 45 FN episodes in 20 patients, 3391 temperature measurements and 318 CBCs, plus information on antibiotics, anti-fungal therapy, antipyretics, blood cultures taken and on discharge were collected. These data can mainly be used to study the influence of virtually lowering the TLDF on diagnostic measures, treatment and length of hospitalization in pediatric FN, which in turn are directly related to costs of FN therapy, and quality of life. This approach can be expanded to include as well different definitions of neutropenia. Measurement(s) | body temperature trait • Blood Cell Count • Diagnostics, Cancer • therapy | Technology Type(s) | Thermometer Device • complete blood cell count • Observational study | Factor Type(s) | day and time • outcome | Sample Characteristic - Organism | Homo sapiens | Sample Characteristic - Environment | hospital |
Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.12118473
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Affiliation(s)
- Eva Brack
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Freiburgstrasse 15, 3010, Bern, Switzerland
| | - Stéphanie Wagner
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Freiburgstrasse 15, 3010, Bern, Switzerland.,Division of Pediatric Nephrology, Department of Pediatrics, Inselspital, Bern University Hospital, Freiburgstrasse 15, 3010, Bern, Switzerland
| | - Eveline Stutz-Grunder
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Freiburgstrasse 15, 3010, Bern, Switzerland.,Department of Pediatric Oncology, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, Freiburgstrasse 15, 3010, Bern, Switzerland
| | - Roland A Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Freiburgstrasse 15, 3010, Bern, Switzerland.
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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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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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31
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Lavieri L, Koenig C, Teuffel O, Agyeman P, Ammann RA. Temperatures and blood counts in pediatric patients treated with chemotherapy for cancer, NCT01683370. Sci Data 2019; 6:108. [PMID: 31270328 PMCID: PMC6610087 DOI: 10.1038/s41597-019-0112-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 05/28/2019] [Indexed: 01/10/2023] Open
Abstract
Fever in neutropenia (FN) is the most frequent potentially lethal complication of chemotherapy in patients with cancer. The temperature limit defining fever (TLDF) for FN is based on scarce evidence. This prospective, single center observational study recruited non-selected pediatric patients diagnosed with cancer between ≥1 and ≤17 years in 2012 and 2013. Of 40 patients potentially eligible, 39 participated. Data of 8896 temperature measurements and 1873 complete blood counts (CBCs) were recorded over 289 months (24.1 years) of chemotherapy exposure time. During this time 43 FN episodes were diagnosed. In 32 episodes, FN diagnosis was based on reaching the local (i.e. Bern, Switzerland) standard TLDF of 39.0 °C; another 11 episodes had been captured by clinical judgement (i.e. temperature < 39.0 °C). These data can be used to simulate the effects of various TLDFs on the rate of FN diagnosis. We assume merging these data with other data sets is feasible. Design Type(s) | observation design • cohort study design • disease detection/diagnosis objective | Measurement Type(s) | body temperature • complete blood cell count | Technology Type(s) | thermometry • blood analyzer | Factor Type(s) | Sample Characteristic(s) | Homo sapiens • whole body • Switzerland |
Machine-accessible metadata file describing the reported data (ISA-Tab format)
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Affiliation(s)
- Luana Lavieri
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Oliver Teuffel
- Division of Oncology, Medical Services of the Statutory Health Insurance Baden-Württemberg, Tübingen, Germany
| | - Philipp Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roland A Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Koenig C, Schneider C, Morgan JE, Ammann RA, Sung L, Phillips B. Association of time to antibiotics and clinical outcomes in patients with fever and neutropenia during chemotherapy for cancer: a systematic review. Support Care Cancer 2019; 28:1369-1383. [DOI: 10.1007/s00520-019-04961-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 06/19/2019] [Indexed: 02/07/2023]
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Delebarre M, Dessein R, Lagrée M, Mazingue F, Sudour-Bonnange H, Martinot A, Dubos F. Differential risk of severe infection in febrile neutropenia among children with blood cancer or solid tumor. J Infect 2019; 79:95-100. [PMID: 31228471 DOI: 10.1016/j.jinf.2019.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To describe and analyze the differences between infections in children with febrile neutropenia (FN) treated for solid tumor or blood cancer. METHODS A prospective study included all episodes of FN in children from April 2007 to April 2016 in 2-pediatric cancer centers in France. Medical history, clinical and laboratory data available at admission and final microbiological data were collected. The proportion of FN, severe infection, categories of microorganisms and outcomes were compared between the two groups. The presumed gateway of the infection was a posteriori considered and evaluated. RESULTS We analyzed 1197 FN episodes (mean age: 8 years). 66% of the FN episodes occurred in children with blood cancer. Severe infections were identified in 23.4% of episodes overall. The rate of severe infection (28.4% vs. 10.4%), types of microorganisms and the need for a management in intensive care unit (2.6% vs. 0.5%) was significantly different between children with blood cancer and solid tumor. Digestive or respiratory presumed gateway of the infections was less frequent for patients with solid tumor. CONCLUSION Given these important microbiological and clinical differences, it may be appropriate to consider differently the risk of severe infection in these two populations and therefore the management of FN.
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Affiliation(s)
- Mathilde Delebarre
- Univ. Lille, CHU Lille, 2 avenue Oscar Lambret, F-59000 Lille, France; EA2694, Public Health, Epidemiology and Quality of Care, F-59000 Lille, France; CHU Lille, Pediatric Emergency Unit & Infectious Diseases, F-59000 Lille, France
| | - Rodrigue Dessein
- Univ. Lille, CHU Lille, 2 avenue Oscar Lambret, F-59000 Lille, France; CHU Lille, Microbiology Unit, Pathology-Biology Center, F-59000 Lille, France
| | - Marion Lagrée
- CHU Lille, Pediatric Emergency Unit & Infectious Diseases, F-59000 Lille, France
| | | | | | - Alain Martinot
- Univ. Lille, CHU Lille, 2 avenue Oscar Lambret, F-59000 Lille, France; EA2694, Public Health, Epidemiology and Quality of Care, F-59000 Lille, France; CHU Lille, Pediatric Emergency Unit & Infectious Diseases, F-59000 Lille, France
| | - François Dubos
- Univ. Lille, CHU Lille, 2 avenue Oscar Lambret, F-59000 Lille, France; EA2694, Public Health, Epidemiology and Quality of Care, F-59000 Lille, France; CHU Lille, Pediatric Emergency Unit & Infectious Diseases, F-59000 Lille, France.
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Koenig C, Morgan J, Ammann RA, Sung L, Phillips B. Protocol for a systematic review of time to antibiotics (TTA) in patients with fever and neutropenia during chemotherapy for cancer (FN) and interventions aiming to reduce TTA. Syst Rev 2019; 8:82. [PMID: 30944024 PMCID: PMC6446276 DOI: 10.1186/s13643-019-1006-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 03/25/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Fever and neutropenia (FN) is a common complication of chemotherapy for cancer. Prompt empiric broad-spectrum antibiotic therapy in FN is typically considered standard of care, but the definition of prompt is not clear. We seek to systematically review the available data on the association between time to antibiotics (TTA) administration and clinical outcomes in patients with FN being treated with chemotherapy. There have been several efforts to reduce TTA in patients with FN, by implementing specific interventions, presuming there will be a beneficial effect on patient-important outcomes. This systematic review will also collect data on such interventions and their effect to reduce TTA and potentially change clinical outcomes. METHODS/DESIGN The search will cover MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, CINAHL, CDSR, CENTRAL, and LILACS. A full-search strategy is provided. Lists of studies identified by references cited and forward citation searching of included articles will also be reviewed. Studies will be screened, and data extracted by one researcher and independently checked by a second. Confounding biases and quality of studies will be assessed with the risk of bias in non-randomised studies-of interventions (ROBINS-I) tool. Data will be presented in narrative and tabular forms; in addition, if appropriate data is available, random effects meta-analysis will be used to examine TTA. A detailed analysis plan, including an assessment of heterogeneity and publication bias, is provided. DISCUSSION This study aims to evaluate the association between TTA and patient-important clinical outcomes. Additionally, it will identify, critically appraise, and synthesise information on performed interventions and its effect to reduce TTA as a way of gaining insight into the potential use of these approaches. This will provide better knowledge for an adjusted treatment approach of FN. SYSTEMATIC REVIEW REGISTRATION PROSPERO [ CRD42018092948 ].
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Affiliation(s)
- Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Jess Morgan
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Roland A. Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lillian Sung
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, UK
- Leeds Children’s Hospital, Leeds, UK
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Zermatten MG, Koenig C, von Allmen A, Agyeman P, Ammann RA. Episodes of fever in neutropenia in pediatric patients with cancer in Bern, Switzerland, 1993-2012. Sci Data 2019; 6:180304. [PMID: 30644854 PMCID: PMC6335615 DOI: 10.1038/sdata.2018.304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/26/2018] [Indexed: 11/09/2022] Open
Abstract
Fever in neutropenia (FN) is the most frequent potentially life threatening complication of chemotherapy for cancer. Prediction of the risk to develop complications, integrated into clinical decision rules, would allow for risk-stratified treatment of FN. This retrospective, single center cohort study in pediatric patients diagnosed with cancer before 17 years, covered two decades, 1993 to 2012. In total, 703 FN episodes in 291 patients with chemotherapy (maximum per patient, 9) were reported here. Twenty-nine characteristics of FN were collected: 6 were patient- and cancer-related, 8 were characteristics of history, 8 of clinical examination, and 7 laboratory results in peripheral blood, all known at FN diagnosis. In total 28 FN outcomes were assessed: 8 described treatment of FN, 6 described microbiologically defined infections (MDI), 4 clinically defined infections, 4 were additional clinical composite outcomes, and 6 outcomes were related to discharge. These data can mainly be used to study FN characteristics and their association with outcomes over time and between centers, and for derivation and external validation of clinical decision rules.
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Affiliation(s)
- Maxime G. Zermatten
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Philipp Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roland A. Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Abstract
Children with cancer have high emergency department (ED) utilization, but little is known about their chief complaints. A retrospective chart review of ED chief complaints for children with cancer (actively receiving therapy) at Riley Hospital for Children from January 2014 to December 2015 was performed. Proportions of visits and disposition for top 5 chief complaints were determined. Multivariate logistic regression analyzed factors associated with admission. There were 598 encounters by 231 children with cancer. About half (49%) had >1 complaint. The 5 most common primary chief complaints were: fever (60.2%), pain (6.5%), nausea/vomiting (5.0%), bleeding (3.9%), and abnormal laboratory values (3.3%). Admission rates varied, with the highest rates being for nausea/vomiting (66.7%). Risk factors for admission were: hospitalization in prior 4 weeks (odds ratio [OR], 2.67; confidence interval [CI], 1.77-4.02), chief complaint of fever (OR, 1.90; CI, 1.16-3.09). For each increase in number of chief complaints, odds increased by 1.45 (CI, 1.14-1.83). Black, non-Hispanic (OR, 0.44; CI, 0.22-0.88) as compared with white, non-Hispanic, younger age (OR, 0.53; CI, 0.29-0.99) or complaint of abnormal laboratory values (OR, 0.20; CI, 0.06-0.68) had lower odds of admission. Children with cancer present to the ED with multiple and varied complaints. Future interventions could aim to improve caregiver anticipatory guidance and ED visit preparedness.
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Haeusler GM, Slavin MA, Bryant PA, Babl FE, Mechinaud F, Thursky KA. Management of fever and neutropenia in children with cancer: A survey of Australian and New Zealand practice. J Paediatr Child Health 2018; 54:761-769. [PMID: 29655245 DOI: 10.1111/jpc.13899] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/19/2017] [Accepted: 12/13/2017] [Indexed: 11/30/2022]
Abstract
AIM Variation in the management of fever and neutropenia (FN) in children is well described. The aim of this study was to explore the current management of FN across Australia and New Zealand and highlight areas for improvement. METHODS A practice survey was administered to paediatric health-care providers via four clinical and research networks. Using three clinical case vignettes, we explored risk stratification, empiric antibiotics, initial investigations, intravenous-oral switch, ambulatory management and antibiotic duration in children with cancer and FN. RESULTS A response was received from 104 participants from 16 different hospitals. FN guideline compliance was rated as moderate or poor by 24% of respondents, and seven different fever definitions were described. There was little variation in the selected empiric monotherapy and dual-therapy regimens, and almost all respondents recommended first-dose antibiotics within 1 h. However, 27 different empiric antibiotic combinations were selected for beta-lactam allergy. An incorrect risk status was assigned to the low-risk case by 27% of respondents and to the high-risk case by 41%. Compared to current practice, significantly more respondents would manage the low-risk case in the ambulatory setting provided adequate resources were in place (43 vs. 85%, P < 0.0001). There was variation in the use of empiric glycopeptides as well as use of aminoglycosides beyond 48 h. CONCLUSION Although the antibiotics selected for empiric management of FN are appropriate and consistent, variation and inaccuracies exist in risk stratification, the selection of monotherapy over dual therapy, empiric antibiotics chosen for beta-lactam allergy, use of glycopeptides and duration of aminoglycosides.
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Paediatric Integrated Cancer Service, Victoria State Government, Melbourne, Victoria, Australia.,Department of Infection and Immunity, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Penelope A Bryant
- Murdoch Children's Research Institute, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Infectious Diseases Unit, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Francoise Mechinaud
- Murdoch Children's Research Institute, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Children's Cancer Centre, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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Haeusler GM, Thursky KA, Slavin MA, Mechinaud F, Babl FE, Bryant P, De Abreu Lourenco R, Phillips R. External Validation of Six Pediatric Fever and Neutropenia Clinical Decision Rules. Pediatr Infect Dis J 2018; 37:329-335. [PMID: 28877157 DOI: 10.1097/inf.0000000000001777] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fever and neutropenia (FN) clinical decision rules (CDRs) are recommended to help distinguish children with cancer at high and low risk of severe infection. The aim of this study was to validate existing pediatric FN CDRs designed to stratify children with cancer at high or low risk of serious infection or medical complication. METHODS Pediatric CDRs suitable for validation were identified from a literature search. Relevant data were extracted from an existing data set of 650 retrospective FN episodes in children with cancer. The sensitivity and specificity of each of the CDR were compared with the derivation studies to assess reproducibility. RESULTS Six CDRs were identified for validation: 2 were designed to predict bacteremia and 4 to predict adverse events. Five CDRs exhibited reproducibility in our cohort. A rule predicting bacteremia had the highest sensitivity (100%; 95% confidence interval (CI): 93%-100%) although poor specificity (17%), with only 15% identified as low risk. For adverse events, the highest sensitivity achieved was 84% (95% CI: 75%-90%), with specificity of 29% and 27% identified as low risk. A rule intended for application after a 24-hour period of inpatient observation yielded a sensitivity of 80% (95% CI: 73-86) and specificity of 46%, with 44% identified as low risk. CONCLUSIONS Five CDRs were reproducible, although not all can be recommended for implementation because of either inadequate sensitivity or failure to identify a clinically meaningful number of low-risk patients. The 24-hour rule arguably exhibits the best balance between sensitivity and specificity in our population.
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Ojha RP, Asdahl PH, Steyerberg EW, Schroeder H. Predicting bacterial infections among pediatric cancer patients with febrile neutropenia: External validation of the PICNICC model. Pediatr Blood Cancer 2018; 65. [PMID: 29286572 DOI: 10.1002/pbc.26935] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/11/2017] [Accepted: 11/22/2017] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The Predicting Infectious Complications in Neutropenic Children and Young People with Cancer (PICNICC) model was recently developed for antibiotic stewardship among pediatric cancer patients, but limited information is available about its clinical usefulness. We aimed to assess the performance of the PICNICC model for predicting microbiologically documented bacterial infections among pediatric cancer patients with febrile neutropenia. MATERIALS AND METHODS We used data for febrile neutropenia episodes at a pediatric cancer center in Aarhus, Denmark between 2000 and 2016. We assessed the area under the receiver operating characteristic curve (AUC), calibration, and clinical usefulness (i.e., net benefit). We also recalibrated the model using statistical updating methods. RESULTS We observed 306 microbiologically documented bacterial infections among 1,892 episodes of febrile neutropenia. The AUC of the model was 0.73 (95% confidence limits [CL]: 0.71-0.75). The calibration intercept (calibration-in-the-large) was -0.69 (95% CL: -0.86 to -0.51) and the slope was 0.77 (95% CL: 0.65-0.89). Modest net benefit was observed at a decision threshold of 5%. Recalibration improved calibration but did not improve net benefit. CONCLUSIONS The PICNICC model has potential for reducing unnecessary antibiotic exposure for pediatric cancer patients with febrile neutropenia, but continued validation and refinement is necessary to optimize clinical usefulness.
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Affiliation(s)
- Rohit P Ojha
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee.,Center for Outcomes Research, JPS Health Network, Fort Worth, Texas
| | - Peter H Asdahl
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Henrik Schroeder
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
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Wagner S, Brack EK, Stutz-Grunder E, Agyeman P, Leibundgut K, Teuffel O, Ammann RA. The influence of different fever definitions on diagnostics and treatment after diagnosis of fever in chemotherapy-induced neutropenia in children with cancer. PLoS One 2018; 13:e0193227. [PMID: 29462193 PMCID: PMC5819814 DOI: 10.1371/journal.pone.0193227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 02/07/2018] [Indexed: 11/18/2022] Open
Abstract
Background There is no evidence-based definition of the temperature limit defining fever (TLDF) in children with neutropenia. Lowering the TLDF is known to increase the number of episodes of fever in neutropenia (FN). This study aimed to investigate the influence of a lower versus standard TLDF on diagnostics and therapy. Methods In a single pediatric cancer center using a high standard TLDF (39°C tympanic-temperature) patients were observed prospectively (NCT01683370). The effect of applying lower TLDFs (range 37.5°C to 38.9°C) versus 39.0°C on these measures was simulated in silicon. Results In reality, 45 FN episodes were diagnosed. Of 3391 temperatures measured, 193 were ≥39.0°C, and 937 ≥38.0°C. For persisting fever ≥24 hours, additional blood cultures were taken in 31 (69%) episodes in reality. This number decreased to 22 (49%) when applying 39.0°C, and increased to 33 for 38.0°C (73%; plus 11 episodes; plus 24%). For persisting fever ≥48 hours, i.v.-antibiotics were escalated in 25 (56%) episodes. This number decreased to 15 (33%) when applying 39.0°C, and increased to 26 for 38.0°C (58%; plus 11 episodes; plus 24%). For persisting fever ≥120 hours, i.v.-antifungals were added in 4 (9%) episodes. This number increased to 6 (13%) by virtually applying 39.0°C, and to 11 for 38.0°C (24%; plus 5 episodes; plus 11%). The median length of stay was 5.7 days (range, 0.8 to 43.4). In 43 episodes with hospital discharge beyond 24 hours, applying 38.0°C led to discharge delay by ≥12 hours in 24 episodes (56%; 95% CI, 40 to 71), with a median delay of 13 hours, and a cumulative delay of 68 days. Conclusion Applying a low versus standard TLDF led to relevant increases of diagnostics, antimicrobial therapy, and length of stay. The differences between management in reality versus simply applying 39.0° as TLDF reflect the important impact of clinical assessment.
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Affiliation(s)
- Stéphanie Wagner
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eva K. Brack
- Department of Infectious Disease and Cancer Research, Children´s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Eveline Stutz-Grunder
- Department of Pediatric Oncology, Children´s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Philipp Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kurt Leibundgut
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Oliver Teuffel
- Division of Oncology, Medical Services of the Statutory Health Insurance Baden-Württemberg, Tübingen, Germany
| | - Roland A. Ammann
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
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Potter BK, Hutton B, Clifford TJ, Pallone N, Smith M, Stockler S, Chakraborty P, Barbeau P, Garritty CM, Pugliese M, Rahman A, Skidmore B, Tessier L, Tingley K, Coyle D, Greenberg CR, Korngut L, MacKenzie A, Mitchell JJ, Nicholls S, Offringa M, Schulze A, Taljaard M. Establishing core outcome sets for phenylketonuria (PKU) and medium-chain Acyl-CoA dehydrogenase (MCAD) deficiency in children: study protocol for systematic reviews and Delphi surveys. Trials 2017; 18:603. [PMID: 29258568 PMCID: PMC5735866 DOI: 10.1186/s13063-017-2327-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 11/13/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Inherited metabolic diseases (IMD) are a large group of rare single-gene disorders that are typically diagnosed early in life. There are important evidence gaps related to the comparative effectiveness of therapies for IMD, which are in part due to challenges in conducting randomized controlled trials (RCTs) for rare diseases. Registry-based RCTs present a unique opportunity to address these challenges provided the registries implement standardized collection of outcomes that are important to patients and their caregivers and to clinical providers and healthcare systems. Currently there is no core outcome set (COS) for studies evaluating interventions for paediatric IMD. This protocol outlines a study that will establish COS for each of two relatively common IMD in children, phenylketonuria (PKU) and medium-chain acyl-CoA dehydrogenase (MCAD) deficiency. METHODS This two-part study is registered with the Core Outcome Measures in Effectiveness Trials (COMET) initiative. Part 1 includes a rapid review and development of an evidence map to identify a comprehensive listing of outcomes reported in past studies of PKU and MCAD deficiency. The review follows established methods for knowledge synthesis, including a comprehensive search strategy, two stages of screening citations against inclusion/exclusion criteria by two reviewers working independently, and extraction of important data elements from eligible studies, including details of the outcomes collected and outcome measurement instruments. The review findings will inform part 2 of our study, a set of Delphi surveys to establish consensus on the highest priority outcomes for each condition. Healthcare providers, families of children with PKU or MCAD deficiency, and health system decision-makers will be invited to participate in two to three rounds of Delphi surveys. The design of the surveys will involve parents of children with IMD who are part of a family advisory forum. DISCUSSION This protocol is a crucial step in developing the capacity to launch RCTs with meaningful outcomes that address comparative effectiveness questions in the field of paediatric IMD. Such trials will contribute high-quality evidence to inform decision-making by patients and their family members, clinicians, and policy-makers.
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Affiliation(s)
- Beth K. Potter
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Drive, Ottawa, ON K1G 5Z3 Canada
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Drive, Ottawa, ON K1G 5Z3 Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Tammy J. Clifford
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Drive, Ottawa, ON K1G 5Z3 Canada
- Canadian Agency for Drugs and Technologies in Health, Ottawa, ON Canada
| | - Nicole Pallone
- Patient/family partner and Canadian PKU & Allied Disorders Inc, Sparwood, BC Canada
| | - Maureen Smith
- Patient/family partner and Canadian Organization for Rare Disorders, Ottawa, ON Canada
| | - Sylvia Stockler
- BC Children’s Hospital and University of British Columbia, Vancouver, BC Canada
| | - Pranesh Chakraborty
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON Canada
| | | | | | - Michael Pugliese
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Drive, Ottawa, ON K1G 5Z3 Canada
| | - Alvi Rahman
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Drive, Ottawa, ON K1G 5Z3 Canada
| | | | - Laure Tessier
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON Canada
| | - Kylie Tingley
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Drive, Ottawa, ON K1G 5Z3 Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Drive, Ottawa, ON K1G 5Z3 Canada
| | | | - Lawrence Korngut
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB Canada
| | - Alex MacKenzie
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON Canada
| | | | - Stuart Nicholls
- Clinical Research Unit, Children’s Hospital of Eastern Ontario, Ottawa, ON Canada
- Ontario Child Health SUPPORT Unit (OCHSU), Ottawa, ON Canada
| | - Martin Offringa
- Hospital for Sick Children and University of Toronto, Toronto, ON Canada
| | - Andreas Schulze
- Hospital for Sick Children and University of Toronto, Toronto, ON Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Drive, Ottawa, ON K1G 5Z3 Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - In collaboration with the Canadian Inherited Metabolic Diseases Research Network
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Drive, Ottawa, ON K1G 5Z3 Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
- Canadian Agency for Drugs and Technologies in Health, Ottawa, ON Canada
- Patient/family partner and Canadian PKU & Allied Disorders Inc, Sparwood, BC Canada
- Patient/family partner and Canadian Organization for Rare Disorders, Ottawa, ON Canada
- BC Children’s Hospital and University of British Columbia, Vancouver, BC Canada
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON Canada
- University of Manitoba, Winnipeg, MB Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB Canada
- McGill University Health Centre, Montreal, QC Canada
- Clinical Research Unit, Children’s Hospital of Eastern Ontario, Ottawa, ON Canada
- Ontario Child Health SUPPORT Unit (OCHSU), Ottawa, ON Canada
- Hospital for Sick Children and University of Toronto, Toronto, ON Canada
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Wolf J, Tang L, Flynn PM, Pui CH, Gaur AH, Sun Y, Inaba H, Stewart T, Hayden RT, Hakim H, Jeha S. Levofloxacin Prophylaxis During Induction Therapy for Pediatric Acute Lymphoblastic Leukemia. Clin Infect Dis 2017; 65:1790-1798. [PMID: 29020310 PMCID: PMC5850441 DOI: 10.1093/cid/cix644] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 07/24/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Infection is the most important cause of treatment-related morbidity and mortality in pediatric patients treated for acute lymphoblastic leukemia (ALL). Although routine in adults with leukemia, antibacterial prophylaxis is controversial in pediatrics because of insufficient evidence for its efficacy or antibiotic choice and concerns about promoting antibiotic resistance and Clostridium difficile infection. METHODS This was a single-center, observational cohort study of patients with newly diagnosed ALL, comparing prospectively collected infection-related outcomes in patients who received no prophylaxis, levofloxacin prophylaxis, or other prophylaxis during induction therapy on the total XVI study. A propensity score-weighted logistic regression model was used to adjust for confounders. RESULTS Of 344 included patients, 173 received no prophylaxis, 69 received levofloxacin prophylaxis, and 102 received other prophylaxis regimens. Patients receiving prophylaxis had longer duration of neutropenia. Prophylaxis reduced the odds of febrile neutropenia, likely bacterial infection, and bloodstream infection by ≥70%. Levofloxacin prophylaxis alone reduced these infections, but it also reduced cephalosporin, aminoglycoside, and vancomycin exposure and reduced the odds of C. difficile infection by >95%. No increase in breakthrough infections with antibiotic-resistant organisms was seen, but this cannot be excluded. CONCLUSIONS This is the largest study to date of antibacterial prophylaxis during induction therapy for pediatric ALL and the first to include a broad-spectrum fluoroquinolone. Prophylaxis prevented febrile neutropenia and systemic infection. Levofloxacin prophylaxis also minimized the use of treatment antibiotics and drastically reduced C. difficile infection. Although long-term antibiotic-resistance monitoring is needed, these data support using targeted prophylaxis with levofloxacin in children undergoing induction chemotherapy for ALL. CLINICAL TRIALS REGISTRATION NCT00549848.
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Affiliation(s)
- Joshua Wolf
- Departments of Infectious Diseases
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | | | - Patricia M Flynn
- Departments of Infectious Diseases
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis
| | - Ching-Hon Pui
- Oncology
- Pathology, St. Jude Children’s Research Hospital
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis
| | - Aditya H Gaur
- Departments of Infectious Diseases
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis
| | | | - Hiroto Inaba
- Oncology
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis
| | | | | | | | - Sima Jeha
- Oncology
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis
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43
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Deane HC, Wilson CL, Babl FE, Dalziel SR, Cheek JA, Craig SS, Oakley E, Borland M, Cheng NG, Zhang M, Cotterell E, Schuster T, Krieser D. PREDICT prioritisation study: establishing the research priorities of paediatric emergency medicine physicians in Australia and New Zealand. Emerg Med J 2017; 35:39-45. [PMID: 28855237 DOI: 10.1136/emermed-2017-206727] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/14/2017] [Accepted: 07/16/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND The Paediatric Research in Emergency Departments International Collaborative (PREDICT) performs multicentre research in Australia and New Zealand. Research priorities are difficult to determine, often relying on individual interests or prior work. OBJECTIVE To identify the research priorities of paediatric emergency medicine (PEM) specialists working in Australia and New Zealand. METHODS Online surveys were administered in a two-stage, modified Delphi study. Eligible participants were PEM specialists (consultants and senior advanced trainees in PEM from 14 PREDICT sites). Participants submitted up to 3 of their most important research questions (survey 1). Responses were collated and refined, then a shortlist of refined questions was returned to participants for prioritisation (survey 2). A further prioritisation exercise was carried out at a PREDICT meeting using the Hanlon Process of Prioritisation. This determined the priorities of active researchers in PEM including an emphasis on the feasibility of a research question. RESULTS One hundred and six of 254 (42%) eligible participants responded to survey 1 and 142/245 (58%) to survey 2. One hundred and sixty-eight (66%) took part in either or both surveys. Two hundred forty-six individual research questions were submitted in survey 1. Survey 2 established a prioritised list of 35 research questions. Priority topics from both the Delphi and Hanlon process included high flow oxygenation in intubation, fluid volume resuscitation in sepsis, imaging in cervical spine injury, intravenous therapy for asthma and vasopressor use in sepsis. CONCLUSION This prioritisation process has established a list of research questions, which will inform multicentre PEM research in Australia and New Zealand. It has also emphasised the importance of the translation of new knowledge.
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Affiliation(s)
- Heather Carol Deane
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Catherine L Wilson
- Emergency Research Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Stuart R Dalziel
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Emergency Department, Starship Children's Hospital, Liggins Institute, University of Auckland, Auckland, New Zealand
| | - John Alexander Cheek
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Paediatric Emergency Department, Monash Medical Centre, Emergency Program, Monash Health, Melbourne, Victoria, Australia
| | - Simon S Craig
- Paediatric Emergency Department, Monash Medical Centre, Emergency Program, Monash Health, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ed Oakley
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Meredith Borland
- Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,Schools of Paediatric and Child Health and Primary, Rural and Aboriginal Healthcare, University of Western Australia, Perth, Western Australia, Australia
| | - Nicholas G Cheng
- Emergency Department, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Michael Zhang
- Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Elizabeth Cotterell
- Tablelands Clinical School, University of New England, Armidale, New South Wales, Australia
| | - Tibor Schuster
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Epidemiology and Biostatistics Unit, Melbourne Children's Trial Centre, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - David Krieser
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Sunshine Hospital, Melbourne, Victoria, Australia
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Haeusler GM, Thursky KA, Mechinaud F, Babl FE, De Abreu Lourenco R, Slavin MA, Phillips R. Predicting Infectious ComplicatioNs in Children with Cancer: an external validation study. Br J Cancer 2017; 117:171-178. [PMID: 28609435 PMCID: PMC5520507 DOI: 10.1038/bjc.2017.154] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 05/09/2017] [Accepted: 05/11/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The aim of this study was to validate the 'Predicting Infectious ComplicatioNs in Children with Cancer' (PICNICC) clinical decision rule (CDR) that predicts microbiologically documented infection (MDI) in children with cancer and fever and neutropenia (FN). We also investigated costs associated with current FN management strategies in Australia. METHODS Demographic, episode, outcome and cost data were retrospectively collected on 650 episodes of FN. We assessed the discrimination, calibration, sensitivity and specificity of the PICNICC CDR in our cohort compared with the derivation data set. RESULTS Using the original variable coefficients, the CDR performed poorly. After recalibration the PICNICC CDR had an area under the receiver operating characteristic (AUC-ROC) curve of 0.638 (95% CI 0.590-0.685) and calibration slope of 0.24. The sensitivity, specificity, positive predictive value and negative predictive value of the PICNICC CDR at presentation was 78.4%, 39.8%, 28.6% and 85.7%, respectively. For bacteraemia, the sensitivity improved to 85.2% and AUC-ROC to 0.71. Application at day 2, taking into consideration the proportion of MDI known (43%), further improved the sensitivity to 87.7%. Length of stay is the main contributor to cost of FN treatment, with an average cost per day of AUD 2183 in the low-risk group. CONCLUSIONS For prediction of any MDI, the PICNICC rule did not perform as well at presentation in our cohort as compared with the derivation study. However, for bacteraemia, the predictive ability was similar to that of the derivation study, highlighting the importance of recalibration using local data. Performance also improved after an overnight period of observation. Implementation of a low-risk pathway, using the PICNICC CDR after a short period of inpatient observation, is likely to be safe and has the potential to reduce health-care expenditure.
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Affiliation(s)
- Gabrielle M Haeusler
- The Paediatric Integrated Cancer Service, 50 Flemington Road, Parkville, Victoria 3052, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria 3010, Australia
- Department of Infection and Immunity, Monash Children’s Hospital, Department of Paediatrics, Monash University, Clayton, Victoria 3168, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria 3010, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Francoise Mechinaud
- Children’s Cancer Centre, Royal Children’s Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Franz E Babl
- Department of Emergency Medicine, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, 15 Broadway, Ultimo, New South Wales 2007, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria 3010, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, Heslington, York YO10 5DD, UK
- Leeds Children’s Hospital, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
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Jones JE, Jones LL, Keeley TJH, Calvert MJ, Mathers J. A review of patient and carer participation and the use of qualitative research in the development of core outcome sets. PLoS One 2017; 12:e0172937. [PMID: 28301485 PMCID: PMC5354261 DOI: 10.1371/journal.pone.0172937] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 02/13/2017] [Indexed: 11/18/2022] Open
Abstract
Background To be meaningful, a core outcome set (COS) should be relevant to all stakeholders including patients and carers. This review aimed to explore the methods by which patients and carers have been included as participants in COS development exercises and, in particular, the use and reporting of qualitative methods. Methods In August 2015, a search of the Core Outcomes Measures in Effectiveness Trials (COMET) database was undertaken to identify papers involving patients and carers in COS development. Data were extracted to identify the data collection methods used in COS development, the number of health professionals, patients and carers participating in these, and the reported details of qualitative research undertaken. Results Fifty-nine papers reporting patient and carer participation were included in the review, ten of which reported using qualitative methods. Although patients and carers participated in outcome elicitation for inclusion in COS processes, health professionals tended to dominate the prioritisation exercises. Of the ten qualitative papers, only three were reported as a clear pre-designed part of a COS process. Qualitative data were collected using interviews, focus groups or a combination of these. None of the qualitative papers reported an underpinning methodological framework and details regarding data saturation, reflexivity and resource use associated with data collection were often poorly reported. Five papers reported difficulty in achieving a diverse sample of participants and two reported that a large and varied range of outcomes were often identified by participants making subsequent rating and ranking difficult. Conclusions Consideration of the best way to include patients and carers throughout the COS development process is needed. Additionally, further work is required to assess the potential role of qualitative methods in COS, to explore the knowledge produced by different qualitative data collection methods, and to evaluate the time and resources required to incorporate qualitative methods into COS development.
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Affiliation(s)
- Janet E. Jones
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Laura L. Jones
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | | | - Melanie J. Calvert
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jonathan Mathers
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
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Delebarre M, Tiphaine A, Martinot A, Dubos F. Risk-stratification management of febrile neutropenia in pediatric hematology-oncology patients: Results of a French nationwide survey. Pediatr Blood Cancer 2016; 63:2167-2172. [PMID: 27569451 DOI: 10.1002/pbc.26121] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/31/2016] [Accepted: 06/06/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND In 2012, new international guidelines for children with chemotherapy-induced febrile neutropenia (FN) were issued, recommending reduced-intensity management strategy based on stratification of infectious risks. Some studies have highlighted practice disparities in different countries and within the same country. Our aim was to assess the current management strategies for the treatment of chemotherapy-induced FN in children in France. PROCEDURE This survey of all French pediatric oncology-hematology reference centers (n = 30) in late 2012 and early 2013 sent a standardized questionnaire to each center inquiring about their definition of an FN episode, its initial empiric treatment and ongoing management, use of management stratified by risk, and any criteria used for the risk assessment. Each center's management protocol was also analyzed. RESULTS All French reference centers participated in this survey, completing 88% of the questionnaire items. Definitions of both fever and neutropenia varied between centers. Ten centers used a risk-stratification strategy for initial management. In all, 42 probabilistic first-line antibiotic treatments were identified. After 48 hr of apyrexia, 17 units applied different forms of step-down therapy. CONCLUSIONS Most French centers already offered some form of reduced-intensity or step-down therapy, although they differed substantially in their management of FN episodes. Risk stratification with validated tools is essential to facilitate the implementation of the international recommendations, which would ultimately help to standardize practices in France.
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Affiliation(s)
- Mathilde Delebarre
- Univ. Lille, CHU Lille, Pediatric Emergency Unit & Infectious Diseases, Lille, France. .,Univ. Lille, EA2694, Public Health, Epidemiology and Quality of Care, Lille, France.
| | - Aude Tiphaine
- Univ. Lille, CHU Lille, Pediatric Emergency Unit & Infectious Diseases, Lille, France.,CHU Bordeaux, Pediatric Hematology-Oncology Unit, Bordeaux, France
| | - Alain Martinot
- Univ. Lille, CHU Lille, Pediatric Emergency Unit & Infectious Diseases, Lille, France.,Univ. Lille, EA2694, Public Health, Epidemiology and Quality of Care, Lille, France
| | - François Dubos
- Univ. Lille, CHU Lille, Pediatric Emergency Unit & Infectious Diseases, Lille, France.,Univ. Lille, EA2694, Public Health, Epidemiology and Quality of Care, Lille, France
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47
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Risk stratification in febrile neutropenic episodes in adolescent/young adult patients with cancer. Eur J Cancer 2016; 64:101-6. [DOI: 10.1016/j.ejca.2016.05.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 04/22/2016] [Accepted: 05/26/2016] [Indexed: 11/18/2022]
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Simon A, Furtwängler R, Graf N, Laws HJ, Voigt S, Piening B, Geffers C, Agyeman P, Ammann RA. Surveillance of bloodstream infections in pediatric cancer centers - what have we learned and how do we move on? GMS HYGIENE AND INFECTION CONTROL 2016; 11:Doc11. [PMID: 27274442 PMCID: PMC4886351 DOI: 10.3205/dgkh000271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pediatric patients receiving conventional chemotherapy for malignant disease face an increased risk of bloodstream infection (BSI). Since BSI may represent an acute life-threatening event in patients with profound immunosuppression, and show further negative impact on quality of life and anticancer treatment, the prevention of BSI is of paramount importance to improve and guarantee patients' safety during intensive treatment. The great majority of all pediatric cancer patients (about 85%) have a long-term central venous access catheter in use (type Broviac or Port; CVAD). Referring to the current surveillance definitions a significant proportion of all BSI in pediatric patients with febrile neutropenia is categorized as CVAD-associated BSI. This state of the art review summarizes the epidemiology and the distinct pathogen profile of BSI in pediatric cancer patients from the perspective of infection surveillance. Problems in executing the current surveillance definition in this patient population are discussed and a new concept for the surveillance of BSI in pediatric cancer patients is outlined.
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Affiliation(s)
- Arne Simon
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Rhoikos Furtwängler
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Norbert Graf
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hans Jürgen Laws
- Klinik für Pädiatrische Onkologie, Hämatologie und Immunologie, Universitätskinderklinik, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Sebastian Voigt
- Klinik für Pädiatrie m. S. Onkologie / Hämatologie / Stammzelltransplantation, Charité – Universitätsmedizin Berlin, Germany
| | - Brar Piening
- Institut für Hygiene und Umweltmedizin, Charité – Universitätsmedizin Berlin, Germany
| | - Christine Geffers
- Institut für Hygiene und Umweltmedizin, Charité – Universitätsmedizin Berlin, Germany
| | - Philipp Agyeman
- Pädiatrische Infektiologie und Pädiatrische Hämatologie-Onkologie, Universitätsklinik für Kinderheilkunde, Inselspital, Bern, Switzerland
| | - Roland A. Ammann
- Pädiatrische Infektiologie und Pädiatrische Hämatologie-Onkologie, Universitätsklinik für Kinderheilkunde, Inselspital, Bern, Switzerland
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Phillips RS, Sung L, Amman RA, Riley RD, Castagnola E, Haeusler GM, Klaassen R, Tissing WJE, Lehrnbecher T, Chisholm J, Hakim H, Ranasinghe N, Paesmans M, Hann IM, Stewart LA. Predicting microbiologically defined infection in febrile neutropenic episodes in children: global individual participant data multivariable meta-analysis. Br J Cancer 2016; 114:623-30. [PMID: 26954719 PMCID: PMC4800297 DOI: 10.1038/bjc.2016.28] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 01/13/2016] [Accepted: 01/16/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Risk-stratified management of fever with neutropenia (FN), allows intensive management of high-risk cases and early discharge of low-risk cases. No single, internationally validated, prediction model of the risk of adverse outcomes exists for children and young people. An individual patient data (IPD) meta-analysis was undertaken to devise one. METHODS The 'Predicting Infectious Complications in Children with Cancer' (PICNICC) collaboration was formed by parent representatives, international clinical and methodological experts. Univariable and multivariable analyses, using random effects logistic regression, were undertaken to derive and internally validate a risk-prediction model for outcomes of episodes of FN based on clinical and laboratory data at presentation. RESULTS Data came from 22 different study groups from 15 countries, of 5127 episodes of FN in 3504 patients. There were 1070 episodes in 616 patients from seven studies available for multivariable analysis. Univariable analyses showed associations with microbiologically defined infection (MDI) in many items, including higher temperature, lower white cell counts and acute myeloid leukaemia, but not age. Patients with osteosarcoma/Ewings sarcoma and those with more severe mucositis were associated with a decreased risk of MDI. The predictive model included: malignancy type, temperature, clinically 'severely unwell', haemoglobin, white cell count and absolute monocyte count. It showed moderate discrimination (AUROC 0.723, 95% confidence interval 0.711-0.759) and good calibration (calibration slope 0.95). The model was robust to bootstrap and cross-validation sensitivity analyses. CONCLUSIONS This new prediction model for risk of MDI appears accurate. It requires prospective studies assessing implementation to assist clinicians and parents/patients in individualised decision making.
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Affiliation(s)
- Robert S Phillips
- Centre for Reviews and Dissemination, University of York, York, UK,Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK,E-mail:
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada,Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Roland A Amman
- Department of Pediatrics, University of Bern, Bern, Switzerland
| | - Richard D Riley
- Department of Primary Care and Health Sciences, Keele University, Keele, UK
| | | | - Gabrielle M Haeusler
- Department of Infectious Diseases and Infection Control, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia,Department of Paediatric Infectious Diseases and The Paediatric Integrated Cancer Service, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Robert Klaassen
- Department of Pediatrics, Division of Hematology/Oncology, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Wim J E Tissing
- Department of Pediatric Oncology, University Of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Julia Chisholm
- Department of Childrens and Young Peoples Oncology, Royal Marsden Hospital, Sutton, Surrey, London, UK
| | - Hana Hakim
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Neil Ranasinghe
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Marianne Paesmans
- EORTC Data Centre and Hopitaux Universitaires Bordet-Erasme—Institut Jules Bordet, Brussels, Belgium
| | - Ian M Hann
- Institute of Child Health and Great Ormond Street Childrens Hospital, London, UK
| | - Lesley A Stewart
- Centre for Reviews and Dissemination, University of York, York, UK
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Mueller EL, Croop J, Carroll AE. Fever and neutropenia hospital discharges in children with cancer: A 2012 update. Pediatr Hematol Oncol 2016; 33:39-48. [PMID: 26900730 DOI: 10.3109/08880018.2015.1102998] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fever and neutropenia (FN) is a common precipitant for hospitalization among children with cancer, but hospital utilization trends are not well described. This study describes national trends for hospital discharges for FN among children with cancer for the year 2012, compared with the authors' previous analysis from 2009. Data were analyzed from the Kids' Inpatient Database (KID), an all-payer US hospital database, for 2012. Pediatric patients with cancer who had a discharge for FN were identified using age ≤19 years, urgent or emergent admit type, nontransferred, and a combination of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for fever and neutropenia. The authors evaluated factors associated with a "short length of stay" (SLOS). Sampling weights were used to permit national inferences. In 2012, children with cancer accounted for 1.8% of pediatric hospital discharges (n = 120,675), with 12.2% (n = 13,456) of cancer-related discharges meeting FN criteria. Two fifths of FN discharges had a SLOS, which accounted for $91 million (2015 US$) in hospital charges. The majority had no serious infections; most common infections were viral infection (9.6%) or upper respiratory infection (9.6%). Factors significantly associated with SLOS included having a diagnosis of ear infection (odds ratio [OR] = 1.54, 95% confidence interval [CI]: 1.16-2.03), soft tissue sarcoma (OR = 1.47, CI: 1.10-1.95), and Hodgkin lymphoma (OR = 1.51, CI: 1.09-2.10), as compared with not having those diagnoses. SLOS admissions continue to be rarely associated with serious infections, but contribute substantially to the burden of hospitalization for pediatric FN. Implementation of risk stratification schemas to identify patients who meet low-risk criteria may decrease financial burden.
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Affiliation(s)
- Emily L Mueller
- a Section of Pediatric Hematology Oncology, Department of Pediatrics , Indiana University School of Medicine , Indianapolis , IN , USA.,b Pediatric and Adolescent Comparative Effectiveness Research , Indiana University , Indianapolis , IN , USA
| | - James Croop
- a Section of Pediatric Hematology Oncology, Department of Pediatrics , Indiana University School of Medicine , Indianapolis , IN , USA
| | - Aaron E Carroll
- b Pediatric and Adolescent Comparative Effectiveness Research , Indiana University , Indianapolis , IN , USA.,c Center for Health Policy and Professionalism Research , Indiana University , Indianapolis , IN , USA
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