Presepsin as a diagnostic marker of bacterial infections in febrile neutropenic pediatric patients with hematological malignancies

Outcome prediction in pediatric fever in neutropenia: Development of clinical decision rules and external validation of published rules based on data from the prospective multicenter SPOG 2015 FN definition study

BACKGROUND

Fever in neutropenia (FN) remains a serious complication of childhood cancer therapy. Clinical decision rules (CDRs) are recommended to help distinguish between children at high and low risk of severe infection. The aim of this analysis was to develop new CDRs for three different outcomes and to externally validate published CDRs.

PROCEDURE

Children undergoing chemotherapy for cancer were observed in a prospective multicenter study. CDRs predicting low from high risk infection regarding three outcomes (bacteremia, serious medical complications (SMC), safety relevant events (SRE)) were developed from multivariable regression models. Their predictive performance was assessed by internal cross-validation. Published CDRs suitable for validation were identified by literature search. Parameters of predictive performance were compared to assess reproducibility.

RESULTS

In 158 patients recruited between April 2016 and August 2018, 360 FN episodes were recorded, including 56 (16%) with bacteremia, 30 (8%) with SMC and 72 (20%) with SRE. The CDRs for bacteremia and SRE used four characteristics (type of malignancy, severely reduced general condition, leucocyte count <0.3 G/L, bone marrow involvement), the CDR for SMC two characteristics (severely reduced general condition and platelet count <50 G/L). Eleven published CDRs were analyzed. Six CDRs showed reproducibility, but only one in both sensitivity and specificity.

CONCLUSIONS

This analysis developed CDRs predicting bacteremia, SMC or SRE at presentation with FN. In addition, it identified six published CDRs that show some reproducibility. Validation of CDRs is fundamental to find the best balance between sensitivity and specificity, and will help to further improve management of FN.

The role of presepsin in pediatric patients with oncological and hematological diseases experiencing febrile neutropenia

Febrile neutropenia (FN) represents one of the main complications of pediatric patients with oncological and hematological diseases. In these patients, it is crucial to identify bacterial infections. The aim of this study is to evaluate presepsin as an early biomarker of bacterial infections during FN. We compared patients with oncological and hematological diseases and a 2:1 age-matched healthy control group. In the FN group, we evaluated 4 biomarkers, namely, C reactive protein (CRP), procalcitonin (PCT), interleukin 6 (IL6) and presepsin at the onset of fever (T0) and 48 h after T0 (T1). In the control group, we only evaluated presepsin. We enrolled a total of 41 children with oncological and hematological diseases disease experiencing 50 FN episodes and 100 healthy patients in the control group. In patients with FN, we found that presepsin was significantly higher than in the control group (p < 0.001). However, in the FN group, we did not find a statistically significant difference between patients with and without bacteremia (p = 0.989 at T0, p = 0.619 at T1). Presepsin values at T1 were higher in patients experiencing an unfavorable outcome (p = 0.025). This study shows that presepsin increases in neutropenic patients, but it only revealed useful in predicting an unfavorable outcome 48 h from the onset of fever.

Febrile illness in high-risk children: a prospective, international observational study

To assess and describe the aetiology and management of febrile illness in children with primary or acquired immunodeficiency at high risk of serious bacterial infection, as seen in emergency departments in tertiary hospitals. Prospective data on demographics, presenting features, investigations, microbiology, management, and outcome of patients within the 'Biomarker Validation in HR patients' database in PERFORM, were analysed. Immunocompromised children (< 18 years old) presented to fifteen European hospitals in nine countries, and one Gambian hospital, with fever or suspected infection and clinical indication for blood investigations. Febrile episodes were assigned clinical phenotypes using the validated PERFORM algorithm. Logistic regression was used to assess the effect size of predictive features of proven/presumed bacterial or viral infection. A total of 599 episodes in 482 children were analysed. Seventy-eight episodes (13.0%) were definite bacterial, 67 episodes probable bacterial (11.2%), and 29 bacterial syndrome (4.8%). Fifty-five were definite viral (9.2%), 49 probable viral (8.2%), and 23 viral syndrome (3.8%). One hundred ninety were unknown bacterial or viral infections (31.7%), and 108 had inflammatory or other non-infectious causes of fever (18.1%). Predictive features of proven/presumed bacterial infection were ill appearance (OR 3.1 (95% CI 2.1-4.6)) and HIV (OR 10.4 (95% CI 2.0-54.4)). Ill appearance reduced the odds of having a proven/presumed viral infection (OR 0.5 (95% CI 0.3-0.9)). A total of 82.1% had new empirical antibiotics started on admission (N = 492); 94.3% proven/presumed bacterial (N = 164), 66.1% proven/presumed viral (N = 84), and 93.2% unknown bacterial or viral infections (N = 177). Mortality was 1.9% (N = 11) and 87.1% made full recovery (N = 522).   Conclusion: The aetiology of febrile illness in immunocompromised children is diverse. In one-third of cases, no cause for the fever will be identified. Justification for standard intravenous antibiotic treatment for every febrile immunocompromised child is debatable, yet effective. Better clinical decision-making tools and new biomarkers are needed for this population. What is Known: • Immunosuppressed children are at high risk for morbidity and mortality of serious bacterial and viral infection, but often present with fever as only clinical symptom. • Current diagnostic measures in this group are not specific to rule out bacterial infection, and positivity rates of microbiological cultures are low. What is New: • Febrile illness and infectious complications remain a significant cause of mortality and morbidity in HR children, yet management is effective. • The aetiology of febrile illness in immunocompromised children is diverse, and development of pathways for early discharge or cessation of intravenous antibiotics is debatable, and requires better clinical decision-making tools and biomarkers.

The Role of Presepsin as a Biomarker of Sepsis in Children: A Systemic Review and Meta-Analysis

Objectives Biomarkers in sepsis are an arena of avid research as they can facilitate timely diagnosis and help reduce mortality. Presepsin is a promising candidate with good diagnostic performance reported in adult and neonatal studies. However, there is no clear consensus about its utility in the pediatric age group. This study aimed to synthesize scientific evidence regarding the diagnostic and prognostic performance of presepsin in pediatric sepsis.

Data Sources A systematic literature search was conducted in MEDLINE/PubMed, Cochrane Central Register of Clinical Trials, Google Scholar, and Scopus to identify relevant studies reporting the diagnostic and prognostic accuracy of presepsin.

Study Selection Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we retrieved all controlled trials and observational studies on presepsin as a biomarker in children aged <19 years with sepsis.

Data Extraction Two authors independently performed study screening, data extraction, and quality assessment of the included studies.

Data Synthesis Among the 267 citations identified, a total of nine relevant studies were included in the final analysis. The pooled diagnostic sensitivity and specificity of presepsin were 0.99 (95% confidence interval [CI]; 0.97–1.00) and 0.88 (95% CI; 0.83–0.92), respectively, with a diagnostic odds ratio (DOR) of 28.15 (95% CI; 0.74–1065.67) and area under the curve (AUC) in summary receiver operating curve of 0.89. Prognostic accuracy for presepsin had a sensitivity of 0.64 (95% CI; 0.35–1.0), specificity of 0.62 (95% CI; 0.44–0.87), and DOR of 3.3 (95% CI; 0.20–53.43). For procalcitonin, the pooled sensitivity for diagnostic accuracy was 0.97 (95% CI; 0.94–1.00), specificity was 0.76 (95% CI; 0.69–0.82), DOR was 10.53 (95% CI; 5.31–20.88), and AUC was 0.81.

Conclusion Presepsin has good diagnostic accuracy with high sensitivity and specificity. Its prognostic accuracy in predicting mortality is low.

Performance of presepsin and procalcitonin predicting culture-proven bacterial infection and 28-day mortality: A cross sectional study

Presepsin is a highly specific biomarker for diagnosing bacterial infections, but its clinical usefulness is not well validated. A retrospective cross-sectional study was conducted. Among the patients suspected bacterial infection or fulfilled the criteria of systemic inflammatory response syndrome (SIRS) and patients who underwent blood culture, presepsin, procalcitonin (PCT), and C-reactive protein (CRP) at the same time were included. Receiver operating characteristic (ROC) curve analysis and logistic regression were used to compare performance of three biomarkers. A total of 757 patients were enrolled, including 256 patients (33.8%) with culture-proven bacterial infection and 109 patients (14.4%) with bacteremia. The 28-day mortality rate was 8.6%. ROC curve analysis revealed that the area under the curve (AUC) of PCT was higher than that of presepsin for both culture-proven bacterial infection (0.665 and 0.596, respectively; p = 0.003) and bacteremia (0.791 and 0.685; p < 0.001). In contrast, AUC of PCT for 28-day mortality was slower than presepsin (0.593 and 0.720; p = 0.002). In multivariable logistic regression analysis, PCT showed the highest ORs for culture-proven bacterial infection (OR 2.23, 95% CI 1.55–3.19; p < 0.001) and for bacteremia (OR 5.18, 95% CI 3.13–8.56; p < 0.001), while presepsin showed the highest OR for 28-day mortality (OR 3.31, 95% CI 1.67–6.54; p < 0.001). CRP did not show better performance than PCT or presepsin in any of the analyses. PCT showed the best performance predicting culture-proven bacterial infection and bacteremia, while presepsin would rather be useful as a prognostic marker.

Biomarkers for Diagnosing Febrile Illness in Immunocompromised Children: A Systematic Review of the Literature

OBJECTIVE

This study aims to assess the performance of biomarkers used for the prediction of bacterial, viral, and fungal infection in immunocompromised children upon presentation with fever.

METHODS

We performed a literature search using PubMed and MEDLINE and In-Process & Other Non-indexed Citations databases. Cohort and case-control studies assessing biomarkers for the prediction of bacterial, viral, or fungal infection in immunocompromised children vs. conventional microbiological investigations were eligible. Studies including adult patients were eligible if pediatric data were separately assessable. Data on definitions used for infections, fever, and neutropenia and predictive values were collected. Risk of bias was assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

RESULTS

Fifty-two studies involving 13,939 febrile episodes in 7,059 children were included. In total, 92.2% were in cancer patients (n = 48), and 15.7% also included hematopoietic stem cell transplantation patients (n = 8). Forty-three biomarkers were investigated, of which 6 (CRP, PCT, IL-8, IL-6, IL-10, and TNFα) were significantly associated with bacterial infection at admission, studied in multiple studies, and provided predictive data. Literature on the prediction of viral and fungal infection was too limited. Eight studies compared C-reactive protein (CRP) and procalcitonin (PCT), with PCT demonstrating superiority in 5. IL-6, IL-8, and IL-10 were compared with CRP in six, four, and one study, respectively, with mixed results on diagnostic superiority. No clear superior biomarker comparing PCT vs. IL-6, IL-8, or IL-10 was identified.

DISCUSSION

There is great heterogeneity in the biomarkers studied and cutoff values and definitions used, thus complicating the analysis. Literature for immunocompromised children with non-malignant disease and for non-bacterial infection is sparse. Literature on novel diagnostics was not available. We illustrated the challenges of diagnosing fever adequately in this study population and the need for improved biomarkers and clinical decision-making tools.

Bloodstream infection in pediatric patients with febrile neutropenia induced by chemotherapy

INTRODUCTION

Febrile neutropenia (FN) is a serious complication of cancer chemotherapy. The present study aimed to identify risk factors for documented infection in pediatric patients with FN and cancer.

METHODS

This prospective cohort study included patients under 18 years from 2016 to 2018. Infection was defined according to the Centers for Disease Control and Prevention criteria.

RESULTS

A total of 172 febrile neutropenic episodes were evaluated. From univariate analysis, the risk factors were: female gender; monocyte count < 100 cell/mm³, platelets < 50,000, C-reactive protein (CRP) > 90 mg/dl and hemoglobin < 7mg/dl at the onset of an episode; two or more episodes of FN, and; fever onset; positive blood culture at the fever onset. Independent risk factors according to the multivariate analysis were: CRP at the onset of a febrile episode > 90mg/dl, fever onset and first blood culture with a positive result. The lowest probability of infection was related to first episode and to platelets > 50,000 at the onset of fever.

CONCLUSION

A CRP > 90 at the onset of a febrile episode, platelets < 50,000, second episode or more, first fever episode during hospitalization and positive first blood culture were found to be associated with a higher risk of infection and they could be useful for the establishment of risk scores for infection in neutropenic children.

Presepsin as Early Marker of Sepsis in Emergency Department: A Narrative Review

The diagnosis and treatment of sepsis have always been a challenge for the physician, especially in critical care setting such as emergency department (ED), and currently sepsis remains one of the major causes of mortality. Although the traditional definition of sepsis based on systemic inflammatory response syndrome (SIRS) criteria changed in 2016, replaced by the new criteria of SEPSIS-3 based on organ failure evaluation, early identification and consequent early appropriated therapy remain the primary goal of sepsis treatment. Unfortunately, currently there is a lack of a foolproof system for making early sepsis diagnosis because conventional diagnostic tools like cultures take a long time and are often burdened with false negatives, while molecular techniques require specific equipment and have high costs. In this context, biomarkers, such as C-Reactive Protein (CRP) and Procalcitonin (PCT), are very useful tools to distinguish between normal and pathological conditions, graduate the disease severity, guide treatment, monitor therapeutic responses and predict prognosis. Among the new emerging biomarkers of sepsis, Presepsin (P-SEP) appears to be the most promising. Several studies have shown that P-SEP plasma levels increase during bacterial sepsis and decline in response to appropriate therapy, with sensitivity and specificity values comparable to those of PCT. In neonatal sepsis, P-SEP compared to PCT has been shown to be more effective in diagnosing and guiding therapy. Since in sepsis the P-SEP plasma levels increase before those of PCT and since the current methods available allow measurement of P-SEP plasma levels within 17 min, P-SEP appears a sepsis biomarker particularly suited to the emergency department and critical care.

Presepsin and Midregional Proadrenomedullin in Pediatric Oncologic Patients with Febrile Neutropenia

OBJECTIVE

In this study, we investigated the roles of presepsin (PSP) and midregional proadrenomedullin (mr-proADM) in children with febrile neutropenia (FN) due to chemotherapy.

METHODS

We assessed 36 FN episodes in 26 children. Patients were classified into bacteremia (B) and fever of unknown origin (FUO) groups. We evaluated PSP and mr-proADM at admission (T0), after 24/48 h (T1), and after 5 days (T2).

RESULTS

PSP and mr-proADM levels were elevated at T0 and significantly decreased at T2. mr-proADM levels did not significantly differ between the B and FUO groups. PSP levels significantly differed between the B and FUO groups only at T1. Both PSP and mr-proADM levels at T0 were a predictor of length of hospital stay but not of the duration of fever. Finally, receiver operating characteristic curve analysis showed that PSP and mr-proADM had low diagnostic accuracy for blood culture positivity.

CONCLUSION

PSP and mr-proADM display poor clinical usefulness for FN in oncologic children.

Usage of Plasma Presepsin, C-Reactive Protein, Procalcitonin and Proadrenomedullin to Predict Bacteremia in Febril Neutropenia of Pediatric Hematological Malignancy Patients

OBJECTIVE

To investigate the value of presepsin and proadrenomedullin (proADM) as new markers for febrile neutropenia, by comparing them with conventional markers.

METHODS

Plasma specimens for presepsin, proADM, C-reactive protein (CRP), and procalcitonin (PCT) were collected every 3 days during each episode of febrile neutropenia.

RESULTS

A total of 39 patients experiencing a collective 47 episodes of febrile neutropenia with hematological malignant neoplasms, as well as 40 healthy control patients without infectious disease, were enrolled in this study. Levels of the studied analytes in the presepsin 1 group (with baseline values taken at admission), presepsin 2 group (values recorded on the 3rd day of febrile neutropenia), and presepsin 3 group (values recorded on the 6th day of hospitalization) were all higher in the subgroups with bacteremia. C-reactive protein 1 (baseline value taken at admission), procalcitonin 1 (as recorded at admission), and procalcitonin 2 (recorded on the 3rd day of febrile neutropenia) were higher in the subroups with bacteremia (P =.03, P = .04, and P = .04, respectively). In multivariate logistic regression analysis, presepsin 1 and/or PCT 1/CRP 1 combined analysis was superior in predicting bacteremia.

CONCLUSION

Presepsin could be used in combination with other biomarkers to detect bacteremia.

Procalcitonin and C-reactive protein predict infection in hematopoietic stem cell transplantation patients

INTRODUCTION

Procalcitonin (PCT) and C-reactive protein (CRP) are known inflammatory markers of severe infection; however, their ability to differentiate between infections of different origins is not clear yet. In this study, we evaluated PCT and CRP as markers of infection in hematopoietic stem cell transplantation (HSCT) patients.

METHODS

Blood samples were collected to determine serum concentrations of PCT, CRP, d-Dimer, and to perform blood culture analysis. Based on blood culture results, the patients were divided into two groups-positive blood culture (n = 271) patients and negative blood culture patients (n = 668); the negative blood culture group served as the control. The positive blood culture group was further divided into three groups based on the etiological agent of infection. PCT and CRP concentrations were compared, and ROC curve, sensitivity, specificity, and cutoff values were calculated.

RESULTS

PCT levels in infected patients were significantly higher than those in control patients (p < 0.001); similarly, CRP and d-Dimer levels were also higher among infected patients when compared with those in the controls. A PCT level of 0.51 ng/mL was the best threshold for detecting the infection, with an AUC-ROC of 0.877, whereas the best threshold for CRP was 49.20 mg/L. PCT levels were the highest in patients with gram-negative bacteremia as compared to in those with gram-positive bacteremia and fungal infection. The optimal cutoff value of PCT for the detection of gram-negative and gram-positive infection was 1.63 ng/mL.

CONCLUSION

PCT seems to be a useful marker for the diagnosis of systemic infection in HSCT patients, probably better than CRP and d-Dimer.

The Association between Dynamic Changes in Serum Presepsin Levels and Mortality in Immunocompromised Patients with Sepsis: A Prospective Cohort Study

Presepsin is a subtype of soluble CD14 that is increased in the blood of septic patients. We investigated the role of dynamic changes in serum presepsin levels in critically ill, immunocompromised patients with sepsis. This is a prospective cohort study that included 119 adult patients admitted to the intensive care unit (ICU). Presepsin level was measured on day 1 and day 3 after ICU admission. The primary outcome was in-hospital mortality. In immunocompromised patients, presepsin levels on day 1 were higher in patients with sepsis than those in patients without sepsis. The area under the curve (AUC) of presepsin for diagnosing sepsis in immunocompromised patients was 0.87, which was comparable with that of procalcitonin (AUC, 0.892). Presepsin levels on day 3 were higher in patients who died in the hospital than in those who survived. In immunocompromised patients who died in the hospital, presepsin levels on day 3 were significantly higher than those on day 1. In the multivariate analysis, ΔPresepsin+ alone was independently correlated with in-hospital mortality in immunocompromised patients. These findings suggest that dynamic changes in presepsin levels between day 1 and day 3 are associated with in-hospital mortality in patients with sepsis, especially in immunocompromised patients.

Pulmonary Infectious Complications in Children with Hematologic Malignancies and Chemotherapy-Induced Neutropenia

Infections frequently complicate the treatment course in children with hematologic malignancies undergoing chemotherapy. Febrile neutropenia (FN) remains a major cause of hospital admissions in this population, and respiratory tract is often proven to be the site of infection even without respiratory signs and symptoms. Clinical presentation may be subtle due to impaired inflammatory response. Common respiratory viruses and bacteria are widely identified in these patients, while fungi and, less commonly, bacteria are the causative agents in more severe cases. A detailed history, thorough clinical and basic laboratory examination along with a chest radiograph are the first steps in the evaluation of a child presenting signs of a pulmonary infection. After stratifying patient’s risk, prompt initiation of the appropriate empirical antimicrobial treatment is crucial and efficient for the majority of the patients. High-risk children should be treated with an intravenous antipseudomonal beta lactam agent, unless there is suspicion of multi-drug resistance when an antibiotic combination should be used. In unresponsive cases, more invasive procedures, including bronchoalveolar lavage (BAL), computed tomography (CT)-guided fine-needle aspiration or open lung biopsy (OLB), are recommended. Overall mortality rate can reach 20% with higher rates seen in cases unresponsive to initial therapy and those under mechanical ventilation.

Procalcitonin Clearance, CD64, and HLA-DR as Predictors of Outcome in Febrile Neutropenic Children With Lymphoreticular Malignancies

BACKGROUND

Febrile neutropenia (FN) is a dreaded complication of cancer chemotherapy. There has been a lot of improvement in supportive care in FN that has drastically reduced the infection-related mortality in these patients. The focus now is on reducing infection-related morbidity, healthcare costs and optimizing the quality of life of the child as well as their family during these episodes. In this study, biomarkers were studied as predictors of outcome so that outcome can be predicted earlier, and treatment modified accordingly.

OBJECTIVE

To measure procalcitonin levels (at baseline and day 3), procalcitonin clearance, neutrophil CD64 expression levels (at baseline) and monocyte HLA-DR expression levels (at baseline), and their correlation with outcome.

SETTING

Tertiary care hospital.

STUDY TYPE

Cross-sectional observational study.

POPULATION/PARTICIPANTS

Sixty-five episodes of FN in children below 12 years with lymphoreticular malignancies. Children receiving antibacterial and/or antifungal treatment within the last 7 days were excluded from the study.

METHODS

The subjects recruited into the study had undergone complete clinical and laboratory evaluation as per hospital protocol. Procalcitonin (day 0 and 3), neutrophil CD64 expression, and monocytic HLA-DR expression levels were measured in these patients.

RESULTS

Sixty-five episodes of FN were studied in children with lymphoreticular malignancy. It was found that procalcitonin and HLA-DR are very good markers of outcome, whereas CD64 although a good marker, was inferior to procalcitonin and HLA-DR in predicting outcome. Procalcitonin clearance was found to be superior to single value of procalcitonin. Furthermore, procalcitonin on day 3 was found to be a better predictor of outcome compared with its baseline value. Also, it was found that procalcitonin and HLA-DR had a significant correlation with baseline C-reactive protein levels.

CONCLUSIONS

On the basis of the findings of the study we suggest that serial monitoring of procalcitonin levels be used in febrile neutropenic children with cancer. Procalcitonin levels on day 3 alone can be offered in resource poor setting. The role of HLA-DR and CD64 also seems promising and needs to be further explored in larger multicentric studies.

Biomarkers in pediatric sepsis: a review of recent literature

Sepsis remains the leading cause of death in infants and children worldwide. Prompt diagnosis and monitoring of infection is pivotal to guide therapy and optimize outcomes. No single biomarker has so far been identified to accurately diagnose sepsis, monitor response and predict severity. We aimed to assess existing evidence of available sepsis biomarkers, and their utility in pediatric population. C-reactive protein and procalcitonin remain the most extensively evaluated and used biomarkers. However, biomarkers related to endothelial damage, vasodilation, oxidative stress, cytokines/chemokines and cell bioproducts have also been identified, often with regard to the site of infection and etiologic pathogen; still, with controversial utility. A multi-biomarker model driven by genomic tools could establish a personalized approach in future disease management.

Can presepsin uniformly respond to various pathogens? - an in vitro assay of new sepsis marker

BACKGROUND

Presepsin (soluble CD14 subtype) is a novel biomarker of sepsis used for early diagnosis. Originally, CD14 is known as the pattern recognition receptor for the lipopolysaccharide (LPS)/LBP complexes, and the diagnostic value of this molecule for gram-positive bacteria, which contain less amount of LPS, is uncertain. To confirm its effectiveness in the diagnosis of bacteremia caused by gram positive bacteria, and to evaluate the interspecies difference of presepsin production against various bacterial strains, we conducted an in vitro assay to evaluate presepsin levels in response to five Gram negative and four Gram positive bacteria.

RESULTS

Whole blood was yielded from five healthy volunteers and co-cultured with bacterial strains at 37 °C for 4 h. Twenty seven clinical isolates of nine species (E. coli, K. pneumoniae, E. cloacae, P. aeruginosa, S. maltophilia, S. aureus, S. pyogenes, B. cereus, and C. striatum) derived from blood cultures of non-neutropenic bacteremia patients were used. Culture supernatants were harvested and presepsin levels were measured. The presepsin level in the gram-negative bacteria 273 (218-352) pg/mL was significantly higher than in the gram-positive bacteria 200 (143-275) pg/mL (p = 0.0002). The presepsin levels were significantly lower in C. striatum, in comparison to other bacteria, and S. pyogenes showed similar results. And the presepsin levels in P. aeruginosa were significantly lower compared to E. cloacae, K. pneumoniae, and S. aureus.

CONCLUSIONS

Presepsin production can also be evoked by gram-positive bacteria, and interspecies differences of presepsin response may exist, which should be considered in the diagnosis of sepsis, especially in certain gram-positive bacteremia such as S. pyogenes or C. striatum.

Pharmacological prophylaxis of infection in pediatric acute myeloid leukemia patients

Introduction: Pediatric patients treated for acute myeloid leukemia (AML) are at high risk of developing severe infectious complications. The choice of an optimum supportive treatment should be based on local epidemiology, as well as intensity and toxicity of the anti-leukemic therapy applied.Areas covered: This review presents an overview of recently published studies focusing on the prevention of infection in pediatric AML patients. PubMed has been systematically searched for clinical trials, reviews, and meta-analyses published in the last 10 years. The focus of this article will be limited to primary prophylaxis only, while secondary prophylaxis is beyond the scope of the current review.Expert opinion: Although anti-bacterial agents may decrease the bacterial infection burden, there is no consensus regarding prophylactic use. To that end, there is a need for further randomized controlled trials to establish the precise role of anti-bacterial prophylaxis in pediatric AML patients. The prophylactic use of anti-fungal agents is strongly recommended for all AML patients. Since the contribution of hematopoietic growth factors to improved survival has not been demonstrated, they should not be routinely applied. Decisions regarding an appropriate prophylactic strategy should be taken in collaboration with the infectious disease experts and pharmacology team.

Comparison of Presepsin, Procalcitonin, Interleukin-8 and C-Reactive Protein in Predicting Bacteraemia in Febrile Neutropenic Adult Patients with Haematological Malignancies

Bacterial infections represent life-threatening complications in patients with febrile neutropenia (FN). Diagnostic biomarkers of infections may help to differentiate bacteraemia from non-bacteraemia FN. We aimed to evaluate the utility of procalcitonin (PCT), presepsin (PS), C-reactive protein (CRP) and interleukin-8 (IL-8) as biomarkers of bacteraemia in adult FN patients with haematological malignancies.

Concentrations of PCT, PS, CRP and IL-8 were prospectively measured in 36 FN episodes experienced by 28 oncohaematological patients.

11 out of 36 episodes were classified as bacteraemia. PCT was the best biomarker to predict bacteraemia with the area under the curve (AUC) ROC of 0,9; specificity 100% and positive predictive value 100%, while the most sensitive was IL-8 (90,9%) with AUC ROC of 0,88 and negative predictive value 95,2%. All patients with PCT concentrations above 1,6 μg/l had bacteraemia. Patients with IL-8 concentrations superior to 170 pg/ml had a 40 times higher risk for bacteraemia than the ones with lower levels. Patients with PS concentrations superior to 410 pg/ml had 24 times higher risk for bacteraemia than the patients with lower levels.

PCT has higher accuracy than CRP, IL-8 and PS in predicting bacteraemia in adult hematologic patients with FN.

Presepsin as a diagnostic marker of sepsis in children and adolescents: a systemic review and meta-analysis

Background

Early diagnosis of sepsis in pediatric patients is vital but remains a major challenge. Previous studies showed that presepsin is potentially a reliable diagnostic biomarker for sepsis in adult and neonates. However, there is no pooled analysis of its efficacy as a diagnostic biomarker for sepsis in children. The aims of the present meta-analysis were to assess the overall diagnostic accuracy of presepsin in pediatric sepsis and compare it to those for C-reactive protein (CRP) and procalcitonin (PCT).

Methods

A systematic literature search was performed in Medline/Pubmed, Embase, the Cochrane Library, and ISI Web of Science to identify relevant studies reporting the diagnostic accuracy of presepsin in patients with pediatric sepsis. Sensitivities and specificities were pooled by bivariate meta-analysis. Heterogeneity was evaluated by χ² test.

Results

We identified 129 studies in total. Most were disqualified on the basis of their titles/abstracts and duplication. Four studies were included in the final analysis. They comprised 308 patients aged between 1 mo and 18 y. The pooled diagnostic sensitivity and specificity of presepsin were 0.94 (95% confidence interval [CI]: 0.74–0.99) and 0.71 (95% CI: 0.35–0.92), respectively. The pooled diagnostic odds ratio, positive likelihood ratio (LR), and negative LR of presepsin were 32.87 (95% CI: 2.12–510.09), 3.24 (95% CI, 1.14–12.38), and 0.08 (95% CI, 0.01–0.74), respectively. Heterogeneity was found in both sensitivity (χ² = 11.17; P = 0.011) and specificity (χ² = 65.78; P < 0.001). No threshold effect was identified among the studies (r = − 0.938). The pooled sensitivity of presepsin (0.94) was higher than that of CRP (0.51) and PCT (0.76), whereas the overall specificity of presepsin (0.71) was lower than that of CRP (0.81) and PCT (0.76). The AUC of presepsin (0.925) was higher than that of CRP (0.715) and PCT (0.820).

Conclusion

Currently available evidence indicates that presepsin has higher sensitivity and diagnostic accuracy, but lower specificity, than PCT or CRP in detecting sepsis in children. However, these results must be carefully interpreted as the number of studies included was small and the studies were statistically heterogeneous.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4397-1) contains supplementary material, which is available to authorized users.

Clinical Approach to the Patient in Critical State Following Immunotherapy and/or Stem Cell Transplantation: Guideline for the On-Call Physician

: The initial management of the hematology patient in a critical state is crucial and poses a great challenge both for the hematologist and the intensive care unit (ICU) physician. After years of clinical practice, there is still a delay in the proper recognition and treatment of critical situations, which leads to late admission to the ICU. There is a much-needed systematic ABC (Airway, Breathing, Circulation) approach for the patients being treated on the wards as well as in the high dependency units because the underlying hematological disorder, as well as disease-related complications, have an increasing frequency. Focusing on score-based decision-making on the wards (Modified Early Warning Score (MEWS), together with Quick Sofa score), active sepsis screening with inflammation markers (C-reactive protein, procalcitonin, and presepsin), and assessment of microcirculation, organ perfusion, and oxygen supply by using paraclinical parameters from the ICU setting (lactate, central venous oxygen saturation (ScVO2), and venous-to-arterial carbon dioxide difference), hematologists can manage the immediate critical patient and improve the overall outcome.