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Santschi M, Ammann RA, Agyeman PKA, Ansari M, Bodmer N, Brack E, Koenig C. 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. PLoS One 2023; 18:e0287233. [PMID: 37531403 PMCID: PMC10395874 DOI: 10.1371/journal.pone.0287233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/21/2023] [Indexed: 08/04/2023] Open
Abstract
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.
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Affiliation(s)
- Marina Santschi
- 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
| | - Philipp K A Agyeman
- Pediatric Infectiology, 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
| | - Nicole Bodmer
- Pediatric Oncology, University Children's Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Eva Brack
- 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
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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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Alali M, Mayampurath A, Dai Y, Bartlett AH. A prediction model for bacteremia and transfer to intensive care in pediatric and adolescent cancer patients with febrile neutropenia. Sci Rep 2022; 12:7429. [PMID: 35523855 PMCID: PMC9076887 DOI: 10.1038/s41598-022-11576-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 04/26/2022] [Indexed: 11/09/2022] Open
Abstract
Febrile neutropenia (FN) is a common condition in children receiving chemotherapy. Our goal in this study was to develop a model for predicting blood stream infection (BSI) and transfer to intensive care (TIC) at time of presentation in pediatric cancer patients with FN. We conducted an observational cohort analysis of pediatric and adolescent cancer patients younger than 24 years admitted for fever and chemotherapy-induced neutropenia over a 7-year period. We excluded stem cell transplant recipients who developed FN after transplant and febrile non-neutropenic episodes. The primary outcome was onset of BSI, as determined by positive blood culture within 7 days of onset of FN. The secondary outcome was transfer to intensive care (TIC) within 14 days of FN onset. Predictor variables include demographics, clinical, and laboratory measures on initial presentation for FN. Data were divided into independent derivation (2009-2014) and prospective validation (2015-2016) cohorts. Prediction models were built for both outcomes using logistic regression and random forest and compared with Hakim model. Performance was assessed using area under the receiver operating characteristic curve (AUC) metrics. A total of 505 FN episodes (FNEs) were identified in 230 patients. BSI was diagnosed in 106 (21%) and TIC occurred in 56 (10.6%) episodes. The most common oncologic diagnosis with FN was acute lymphoblastic leukemia (ALL), and the highest rate of BSI was in patients with AML. Patients who had BSI had higher maximum temperature, higher rates of prior BSI and higher incidence of hypotension at time of presentation compared with patients who did not have BSI. FN patients who were transferred to the intensive care (TIC) had higher temperature and higher incidence of hypotension at presentation compared to FN patients who didn't have TIC. We compared 3 models: (1) random forest (2) logistic regression and (3) Hakim model. The areas under the curve for BSI prediction were (0.79, 0.65, and 0.64, P < 0.05) for models 1, 2, and 3, respectively. And for TIC prediction were (0.88, 0.76, and 0.65, P < 0.05) respectively. The random forest model demonstrated higher accuracy in predicting BSI and TIC and showed a negative predictive value (NPV) of 0.91 and 0.97 for BSI and TIC respectively at the best cutoff point as determined by Youden's Index. Likelihood ratios (LRs) (post-test probability) for RF model have potential utility of identifying low risk for BSI and TIC (0.24 and 0.12) and high-risk patients (3.5 and 6.8) respectively. Our prediction model has a very good diagnostic performance in clinical practices for both BSI and TIC in FN patients at the time of presentation. The model can be used to identify a group of individuals at low risk for BSI who may benefit from early discharge and reduced length of stay, also it can identify FN patients at high risk of complications who might benefit from more intensive therapies at presentation.
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Affiliation(s)
- Muayad Alali
- Department of Pediatrics, Division of Infectious Diseases, University of Chicago Medicine, Chicago, IL, USA.
| | - Anoop Mayampurath
- Department of Pediatrics, The University of Chicago, Chicago, IL, USA
- Center for Research Informatics, The University of Chicago, Chicago, IL, USA
| | - Yangyang Dai
- Center for Research Informatics, The University of Chicago, Chicago, IL, USA
| | - Allison H Bartlett
- Department of Pediatrics, Division of Infectious Diseases, University of Chicago Medicine, Chicago, IL, USA
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Clinical Utility of Total Oxidative Stress and Total Antioxidant Capacity in Childhood Febrile Neutropenia. J Pediatr Hematol Oncol 2022; 44:142-146. [PMID: 35446801 DOI: 10.1097/mph.0000000000002277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022]
Abstract
The aim is to determine the oxidative status of children with febrile neutropenia (FEN). Blood samples were collected to determine the total antioxidant capacity (TAC) and total oxidative status (TOS) of healthy children (once) and children with FEN after 0, 48, and 96 hours. Eighteen patients with FEN were evaluated. The baseline TAC level of patients was significantly higher than that of the controls (P<0.0001). The TAC levels of patients with FEN with and without antibiotic modification were higher than those of the controls (P=0.002 and 0.02, respectively). The TAC levels of the patients with FEN with antibiotic modification were lower than those of the patients without antibiotic modification (P=0.0224). The oxidative stress index (OSI), calculated TOS/TAS, value of the children with FEN was lower than that of the controls (P<0.0001). The OSI values of the patients with FEN with and without antibiotic modification were lower than those of the control group (P=0.001 and <0.0001, respectively). The TAC values of the patients with antibiotic modification were higher than those of the patients without antibiotic modification (P=0.02). In conclusion, the oxidative status of the children with FEN was affected, and it can give information about the follow-up of FEN.
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McBee MP, Woodhouse C, Trout AT, Geller JI, Smith EA, Zhang B, Towbin AJ. Skeletal muscle mass as a marker to predict outcomes in children and young adults with cancer. Abdom Radiol (NY) 2022; 47:452-459. [PMID: 34625830 DOI: 10.1007/s00261-021-03301-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE Nutrition is an important outcome predictor in oncology patients including treatment response, physical disability, quality of life, and overall survival. Sarcopenia (loss of skeletal muscle mass and function) is a demonstrated marker of nutritional status in adults, but data are more limited in children. The purpose of this study was to evaluate whether total psoas muscle area (tPMA) measured at the time of cancer diagnosis predicts overall survival (OS), disease free survival (DFS), or number of days neutropenic. METHODS A retrospective study was performed. tPMA was measured at the L3 and L4 mid-lumbar vertebral body level by a single reviewer on cross-sectional imaging studies performed within 2 weeks of primary oncologic diagnosis for all oncology patients who received their primary therapy at Cincinnati Children's Hospital between 1/1/2000 and 12/31/2013. Spearman's correlation was used to assess the association between tPMA and OS, DFS, days neutropenic, and adjusted days neutropenic. Subanalysis was performed assessing the relationship of tumor type and age at diagnosis with each parameter. RESULTS 164 patients (median age 9.9 years; 89 M/75 F) were included in the study. Days neutropenic and normalized days neutropenic were significantly but weakly negatively correlated with tPMA at L3 (r = - 0.24, p < 0.002 and r = - 0.18, p < 0.05 respectively) and L4 (r = - 0.25, p < 0.002; and and r = - 0.19, p < 0.02 respectively). At subanalysis, the correlation between anthropometric features and normalized days neutropenic was only seen with brain tumors. There was no statistically significant relationship between sarcopenia at diagnosis and DFS or OS overall or in subanalysis. CONCLUSION There is a weak inverse relationship between days neutropenic and psoas muscle bulk in pediatric and young adult oncology patients suggesting a relationship between nutritional status and cell recovery. Measures of sarcopenia, however, did not correlate with DFS or OS.
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Affiliation(s)
- Morgan P McBee
- Department of Radiology and Radiological Science, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29245, USA
- Department of Pediatrics, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC, 29245, USA
| | - Cody Woodhouse
- Department of Neurosurgery, 320 E North Ave, Pittsburgh, PA, 15212, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA
| | - James I Geller
- Division of Oncology, Cincinnati Children's Hospital, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Ethan A Smith
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA
| | - Bin Zhang
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
- Department of Radiology, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA.
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Huschart E, Ducore J, Chung J. Assessing Safe Discharge Criteria for Pediatric Oncology Patients Admitted for Febrile Neutropenia. J Pediatr Hematol Oncol 2021; 43:e880-e885. [PMID: 33625079 DOI: 10.1097/mph.0000000000002074] [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: 06/25/2020] [Accepted: 12/16/2020] [Indexed: 11/25/2022]
Abstract
Recent studies suggest outpatient therapy, oral antibiotics, or earlier discharge could be appropriate in some pediatric patients admitted with febrile neutropenia; supporting data are lacking. Retrospective chart review of patients admitted from September 2005 through October 2016 identified 131 "early discharge" febrile neutropenia admissions with discharge absolute neutrophil count (ANC) <500/µl and negative cultures. All were afebrile and discharged without outpatient antibiotics. Eleven of 131 patients (8%) were readmitted. Two patients called back for late positive cultures. Nine were readmitted with febrile neutropenia; 2 had positive cultures on readmission. All 4 patients with positive cultures were safely treated with appropriate antibiotics. The remaining 7 patients had uneventful readmissions. Average ANC (SD) at discharge was lower for patients readmitted versus those not readmitted (69 [70] vs. 196 [145], P≤0.001), as was absolute phagocyte count (APC) at discharge (97 [82] vs. 453 [431], P≤0.001). APC on admission was not significantly lower for those readmitted (165 [254] vs. 321 [388], P=0.09). Few patients required readmission; those with bacterial infections were easily identified and appropriately treated. Higher ANC or APC criteria for discharge would increase length of hospital stay without decreasing morbidity. A subset of patients admitted with febrile neutropenia can be safely discharged before count recovery without oral antibiotics.
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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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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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9
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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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Arif T, Phillips RS. Updated systematic review and meta-analysis of the predictive value of serum biomarkers in the assessment and management of fever during neutropenia in children with cancer. Pediatr Blood Cancer 2019; 66:e27887. [PMID: 31250539 DOI: 10.1002/pbc.27887] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/01/2019] [Accepted: 06/03/2019] [Indexed: 11/12/2022]
Abstract
Routinely measurable biomarkers as predictors for adverse outcomes in febrile neutropenia could improve management through risk stratification. This systematic review assesses the predictive role of biomarkers in identifying events such as bacteraemia, clinically documented infections, microbiologically documented infection, severe sepsis requiring intensive care or high dependency care and death. This review collates 8319 episodes from 4843 patients. C-reactive protein (CRP), interleukin (IL)-6, IL-8 and procalcitonin (PCT) consistently predict bacteraemia and severe sepsis; other outcomes have highly heterogeneous results. Performance of the biomarkers at admission using different thresholds demonstrates that PCT > 0.5 ng/mL offers the best compromise between sensitivity and specificity: sensitivity 0.67 (confidence interval [CI] 0.53-0.79) specificity 0.73 (CI 0.66-0.77). Seventeen studies describe the use of serial biomarkers, with PCT having the greatest discriminatory role. Biomarkers, potentially with serial measurements, may predict adverse outcomes in paediatric febrile neutropenia and their role in risk stratification is promising.
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Affiliation(s)
- Tasnim Arif
- Department of Paediatric Haematology and Oncology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Robert S Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom.,Department of Paediatric Haematology and Oncology, Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom
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11
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Allaway Z, Phillips RS, Thursky KA, Haeusler GM. Nonneutropenic fever in children with cancer: A scoping review of management and outcome. Pediatr Blood Cancer 2019; 66:e27634. [PMID: 30724005 DOI: 10.1002/pbc.27634] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/17/2018] [Accepted: 01/10/2019] [Indexed: 12/17/2022]
Abstract
To date, very few studies have addressed nonneutropenic fever (NNF) in children with cancer, and there are no consensus guidelines. This scoping review aims to describe the rate of bacteremia, risk factors for infection and management, and outcomes of NNF in this population. Across 15 studies (n = 4106 episodes), the pooled-average bacteremia rate was 8.2%, and risk factors included tunneled external central venous catheter, clinical instability, and higher temperature. In two studies, antibiotics were successfully withheld in a subset of low-risk patients. Overall outcomes of NNF appear favorable; however, further research is required to determine its true clinical and economic impact.
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Affiliation(s)
- Zoe Allaway
- The Paediatric Integrated Cancer Service, Parkville, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Robert S Phillips
- Centre for Reviews and Dissemination, University of York, Heslington, York, UK.,Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.,NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Gabrielle M Haeusler
- The Paediatric Integrated Cancer Service, Parkville, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.,NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,Infectious Diseases Unit, Department of General Paediatrics, The Royal Children's Hospital, Parkville, Victoria, Australia
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12
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Morgan JE. Fifteen minute consultation: Fever in children being treated for cancer. Arch Dis Child Educ Pract Ed 2019; 104:124-128. [PMID: 30104324 DOI: 10.1136/archdischild-2017-314718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 11/03/2022]
Abstract
Fever is a common symptom in children receiving treatment for cancer. Clinicians and families are most concerned about febrile neutropenia, though non-neutropenic fever often causes more challenging treatment dilemmas. This article provides a structured approach to the initial assessment, examination, investigation and risk assessment of children with fever during treatment for childhood cancer. Non-neutropenic fever in children with cancer is not well researched. There are no systematic reviews of its management and no National Institute for Health and Care Excellence (NICE) (or other international) guidance about what to do. Features to consider when managing non-neutropenic fever are discussed. Febrile neutropenia, meanwhile, is an oncological emergency and requires management using standard sepsis principles including administration of broad-spectrum antibiotics. Relevant NICE guidance provides a clear structure for treatment. Ongoing management depends on the response to initial treatment.
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Febrile Neutropenia in Transplant Recipients. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7122322 DOI: 10.1007/978-1-4939-9034-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Febrile neutropenic patients are at increased risk of developing infections. During the initial stages of neutropenia, most of these infections are bacterial. The spectrum of bacterial infections depends to some extent on whether or not patients receive antimicrobial prophylaxis when neutropenic. Since most transplant recipients do, Gram-positive organisms predominate, due to the fact prophylaxis is directed primarily against Gram-negative organisms. Staphylococcus species (often methicillin-resistant), Streptococcus species (viridans group streptococci, beta-hemolytic streptococci), and Enterococcus species (including vancomycin-resistant strains) are isolated most often. Therefore, potent empiric Gram-positive coverage is recommended by many in this setting. Escherichia coli, Pseudomonas aeruginosa, and Klebsiella species are the most common Gram-negative pathogens isolated. Non-fermentative Gram-negative bacilli (Stenotrophomonas maltophilia, Acinetobacter species) are emerging as important pathogens. Many of these organisms acquire multiple mechanisms of resistance that render them multidrug resistant. The administration of prompt, broad-spectrum, empiric, antimicrobial therapy is essential and is generally based on local epidemiology and susceptibility/resistance patterns. Response rate to the initial regimen is generally in the range of 75–85%. Fungal infections develop in patients with prolonged neutropenia (greater than 7–10 days). Candida species and Aspergillus species are the predominant fungal pathogens, although many other fungi are opportunistic pathogens in this setting. Fungal infections are seldom documented microbiologically or on histopathology, and the administration of empiric antifungal therapy, when such infections are suspected, is the norm. Therapy is often prolonged, and outcomes are still suboptimal. The importance of infection control and antimicrobial stewardship cannot be overemphasized.
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14
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Green LL, Goussard P, van Zyl A, Kidd M, Kruger M. Predictive Indicators to Identify High-Risk Paediatric Febrile Neutropenia in Paediatric Oncology Patients in a Middle-Income Country. J Trop Pediatr 2018; 64:395-402. [PMID: 29149345 DOI: 10.1093/tropej/fmx082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE To validate a clinical risk prediction score (Ammann score) to predict adverse events (AEs) in paediatric febrile neutropenia (FN). PATIENTS AND METHODS Patients <16 years of age were enrolled. A risk prediction score (based on haemoglobin ≥ 9 g/dl, white cell count (WCC) < 0.3 G/l, platelet count <50 G/l and chemotherapy more intensive than acute lymphoblastic leukaemia maintenance therapy) was calculated and AEs were documented. RESULTS In total, 100 FN episodes occurred in 52 patients, male:female ratio was 1.8:1 and median age was 56 months. At reassessment, AEs occurred in 18 of 55 (45%) low-risk FN episodes (score < 9) and 21 of 42 (55%) high-risk episodes (score ≥9) (sensitivity 60%, specificity 65%, positive predictive value 53%, negative predictive value 71%). Total WCC and absolute monocyte count (AMC) were significantly associated with AEs. CONCLUSION This study identified total WCC and AMC as significantly associated with AEs but failed to validate the risk prediction score.
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Affiliation(s)
- Lindy-Lee Green
- Paediatric Oncology Unit, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Francie van Zijl Drive, Tygerberg, Cape Town, South Africa
| | - Pierre Goussard
- Paediatric Oncology Unit, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Francie van Zijl Drive, Tygerberg, Cape Town, South Africa
| | - Anel van Zyl
- Paediatric Oncology Unit, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Francie van Zijl Drive, Tygerberg, Cape Town, South Africa
| | - Martin Kidd
- Centre for Statistical Consultation, Department of Statistics and Actuarial Sciences, University of Stellenbosch, Van der Stel building, Bosman Road Stellenbosch, Private Bag X1, Matieland, Stellenbosch, South Africa
| | - Mariana Kruger
- Paediatric Oncology Unit, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Francie van Zijl Drive, Tygerberg, Cape Town, South Africa
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15
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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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16
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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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17
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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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18
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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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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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20
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Which Variables Are Useful for Predicting Severe Infection in Children With Febrile Neutropenia? J Pediatr Hematol Oncol 2015; 37:e468-74. [PMID: 26479996 DOI: 10.1097/mph.0000000000000440] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To distinguish children with chemotherapy-induced febrile neutropenia (FN) at low risk of severe infection, the variables that are significant risk factors must be identified. Our objective was to identify them by applying evidence-based standards. This retrospective 2-center cohort study included all episodes of chemotherapy-induced FN in children in 2005 and 2006. The medical history, clinical, and laboratory data available at admission were collected. Severe infection was defined by bacteremia, a positive culture of a normally sterile body fluid, invasive fungal infection, or localized infection at high risk of extension. Univariate analysis identified potential predictive variables. A generalized mixed model was used to determine the adjusted variables that predict severe infection. We analyzed 372 FN episodes. Severe infections occurred in 16.1% of them. Variables predictive of severe infection at admission were: disease with high risk of prolonged neutropenia (adjusted odds ratio [aOR]=2.5), blood cancer (aOR=1.9), fever ≥38.5°C (aOR=3.7), and C-reactive protein level ≥90 mg/L (aOR=4.5). Now that we have identified these variables significantly associated with the risk of severe infection, they must be validated prospectively before combining the best predictive variables in a decision rule that can be used to distinguish children at low risk.
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Penel-Page M, Normand C, Bertrand A, Levard A, Boyle H, Riberon C, Marec-Berard P. [Management of febrile neutropenias in adolescents and young adults: Differences of practice between adult and pediatric units]. Bull Cancer 2015; 102:915-22. [PMID: 26384690 DOI: 10.1016/j.bulcan.2015.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 07/15/2015] [Accepted: 08/04/2015] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Adolescents and young adults (AYA, 15-25years old) with cancer are treated either in adult or pediatric units. Management of febrile neutropenia (FN) is different between these units. Monitoring rules and indications of hospitalization are often stricter in pediatrics. This study evaluates if these differences influence the occurrence of complications. METHODS The medical records of AYA patients treated in our institution in the Euro-E-W-I-N-G99 protocol between 01/09/2000 and 31/05/2013 were retrospectively analyzed. We studied febrile neutropenias occurring after VIDE courses, during the induction period. RESULTS Forty-four patients were included (18 from adult units, 26 from pediatrics). Median age at inclusion was 19.6. After 260 courses of VIDE, we observed a median of 2 FN per adult and 3 per pediatric patient (P=0.2). Hospitalization occurred in median 1.5 time per adult and 3 per pediatric patient (P=0.008). Median cumulated length of stay was 4.5days for adults versus 16 days for pediatric patients (P=0.008). There was no significant difference for survival, number of documented infections, transfusions, dose modifications, chemotherapy delay, need for intensive care, infection after post-induction surgery. CONCLUSION AYA treated in adult services are less frequently hospitalized for FN with no difference in morbi-mortality. Homogeneous recommendations could be made for these patients, whatever the units they are treated in.
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Affiliation(s)
- Mathilde Penel-Page
- Institut d'hématologie et d'oncologie pédiatrique (IHOP), 1, place Joseph-Renaut, 69008 Lyon, France; Université Claude-Bernard Lyon 1 69008 Lyon, France.
| | - Charline Normand
- Institut d'hématologie et d'oncologie pédiatrique (IHOP), 1, place Joseph-Renaut, 69008 Lyon, France
| | - Amandine Bertrand
- Institut d'hématologie et d'oncologie pédiatrique (IHOP), 1, place Joseph-Renaut, 69008 Lyon, France
| | - Alice Levard
- Centre Léon-Bérard (CLB), 28, rue Laennec, 69008 Lyon, France
| | - Helen Boyle
- Dispositif adolescents-jeunes adultes, commun au CLB et à l'IHOP (DAJAC), 28, rue Laennec, 69008 Lyon, France
| | - Christèle Riberon
- Dispositif adolescents-jeunes adultes, commun au CLB et à l'IHOP (DAJAC), 28, rue Laennec, 69008 Lyon, France
| | - Perrine Marec-Berard
- Dispositif adolescents-jeunes adultes, commun au CLB et à l'IHOP (DAJAC), 28, rue Laennec, 69008 Lyon, France; Université Claude-Bernard Lyon 1 69008 Lyon, France
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Salstrom JL, Coughlin RL, Pool K, Bojan M, Mediavilla C, Schwent W, Rannie M, Law D, Finnerty M, Hilden J. Pediatric patients who receive antibiotics for fever and neutropenia in less than 60 min have decreased intensive care needs. Pediatr Blood Cancer 2015; 62:807-15. [PMID: 25663663 PMCID: PMC4413050 DOI: 10.1002/pbc.25435] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/27/2014] [Accepted: 12/29/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND Antibiotic delivery to patients with fever and neutropenia (F&N) in <60 min is an increasingly important quality measure for oncology centers, but several published reports indicate that a time to antibiotic delivery (TTA) of <60 min is quite difficult to achieve. Here we report a quality improvement (QI) effort that sought to decrease TTA and assess associated clinical outcomes in pediatric patients with cancer and F&N. PROCEDURE We used Lean-Methodology and a Plan-Do-Study-Act approach to direct QI efforts and prospectively tracked TTA measures and associated clinical outcomes (length of stay, duration of fever, use of imaging studies to search for occult infection, bacteremia, intensive care unit (ICU) consultation or admission, and mortality). We then performed statistical analysis to determine the impact of our QI interventions on total TTA, sub-process times, and clinical outcomes. RESULTS Our QI interventions significantly improved TTA such that we are now able to deliver antibiotics in <60 min nearly 100% of the time. All TTA sub-process times also improved. Moreover, achieving TTA <60 min significantly reduced the need for ICU consultation or admission (P = 0.003) in this population. CONCLUSION Here we describe our QI effort along with a detailed assessment of several associated clinical outcomes. These data indicate that decreasing TTA to <60 min is achievable and associated with improved outcomes in pediatric patients with cancer and F&N.
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Affiliation(s)
- Jennifer L Salstrom
- Center for Cancer and Blood Disorders, Children's Hospital ColoradoAurora, Colorado,Department of Pediatrics, University of Colorado Denver Anschutz Medical CampusAurora, Colorado,Department of Biochemistry and Molecular Genetics, University of Colorado Denver Anschutz Medical CampusAurora, Colorado,*Correspondence to: Jennifer L. Salstrom, Department of Biochemistry and Molecular Genetics, University of Colorado Anschutz Medical Campus, 12801 E 17th Ave, MS 8101, L18–9401A, Aurora, CO 80045., E-mail:
| | - Rebecca L Coughlin
- Center for Cancer and Blood Disorders, Children's Hospital ColoradoAurora, Colorado,Process Improvement, Children's Hospital ColoradoAurora, Colorado
| | - Kathleen Pool
- Center for Cancer and Blood Disorders, Children's Hospital ColoradoAurora, Colorado
| | - Melissa Bojan
- Center for Cancer and Blood Disorders, Children's Hospital ColoradoAurora, Colorado
| | - Camille Mediavilla
- Center for Cancer and Blood Disorders, Children's Hospital ColoradoAurora, Colorado
| | - William Schwent
- Process Improvement, Children's Hospital ColoradoAurora, Colorado
| | - Michael Rannie
- Clinical Informatics, Children's Hospital ColoradoAurora, Colorado
| | - Dawn Law
- Clinical Informatics, Children's Hospital ColoradoAurora, Colorado
| | - Michelle Finnerty
- Clinical Application Services, Children's Hospital ColoradoAurora, Colorado
| | - Joanne Hilden
- Center for Cancer and Blood Disorders, Children's Hospital ColoradoAurora, Colorado,Department of Pediatrics, University of Colorado Denver Anschutz Medical CampusAurora, Colorado
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Haeusler GM, Phillips RS, Lehrnbecher T, Thursky KA, Sung L, Ammann RA. Core outcomes and definitions for pediatric fever and neutropenia research: a consensus statement from an international panel. Pediatr Blood Cancer 2015; 62:483-9. [PMID: 25446628 DOI: 10.1002/pbc.25335] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 10/03/2014] [Indexed: 11/05/2022]
Abstract
BACKGROUND There are no specific recommendations for the design and reporting of studies of children with fever and neutropenia (FN). As a result, there is marked heterogeneity in the variables and outcomes that are reported and new definitions continue to emerge. These inconsistencies hinder the ability of researchers and clinicians to compare, contrast and combine results. The objective was to achieve expert consensus on a core set of variables and outcomes that should be measured and reported, as a minimum, in pediatric FN studies. PROCEDURE The Delphi method was used to achieve consensus among an international group of clinicians, pharmacists, researchers, and patient representatives. Four surveys focusing on (i) the identification of a core set of variables and outcomes; and (ii) definitions of these variables and outcomes, were administered electronically. Consensus was predefined as more than 80% agreement on any statement. RESULTS There were forty-five survey participants and the response rate ranged between 84 and 96%. There was consensus on eight core variables and 10 core outcomes that should be collected and reported in all studies of children with FN. Consensus definitions were identified for all of the core outcomes. CONCLUSION Using the Delphi method, expert consensus on a set of core variables and outcomes, and their corresponding definitions, was achieved. These core sets represent the minimum that should be collected and reported in all studies of children with FN. This will promote collaboration and ensure consistency and comparability between studies.
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious Diseases and Infection Control, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Infectious Diseases, Monash Children's Hospital, Monash Health, Melbourne, Australia; Paediatric Integrated Cancer Service, Victoria, Australia
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Moons KGM, Altman DG, Reitsma JB, Ioannidis JPA, Macaskill P, Steyerberg EW, Vickers AJ, Ransohoff DF, Collins GS. Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration. Ann Intern Med 2015; 162:W1-73. [PMID: 25560730 DOI: 10.7326/m14-0698] [Citation(s) in RCA: 2836] [Impact Index Per Article: 315.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) Statement includes a 22-item checklist, which aims to improve the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. This explanation and elaboration document describes the rationale; clarifies the meaning of each item; and discusses why transparent reporting is important, with a view to assessing risk of bias and clinical usefulness of the prediction model. Each checklist item of the TRIPOD Statement is explained in detail and accompanied by published examples of good reporting. The document also provides a valuable reference of issues to consider when designing, conducting, and analyzing prediction model studies. To aid the editorial process and help peer reviewers and, ultimately, readers and systematic reviewers of prediction model studies, it is recommended that authors include a completed checklist in their submission. The TRIPOD checklist can also be downloaded from www.tripod-statement.org.
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Ammann RA, Niggli FK, Leibundgut K, Teuffel O, Bodmer N. Exploring the association of hemoglobin level and adverse events in children with cancer presenting with fever in neutropenia. PLoS One 2014; 9:e101696. [PMID: 25020130 PMCID: PMC4096594 DOI: 10.1371/journal.pone.0101696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 06/10/2014] [Indexed: 11/25/2022] Open
Abstract
Background In children and adolescents with fever in neutropenia (FN) during chemotherapy for cancer, hemoglobin ≥90 g/L at presentation with FN had been associated with adverse events (AE). This analysis explored three hypothetical pathophysiological mechanisms potentially explaining this counterintuitive finding, and further analyzed the statistical association between hemoglobin and AE. Methods Two of 8 centers, reporting on 311 of 421 FN episodes in 138 of 215 patients participated in this retrospective analysis based on prospectively collected data from three databases (SPOG 2003 FN, transfusion and hematology laboratories). Associations with AE were analyzed using mixed logistic regression. Results Hemoglobin was ≥90 g/L in 141 (45%) of 311 FN episodes, specifically in 59/103 (57%) episodes with AE, and in 82/208 (39%) without (OR, 2.3; 99%CI, 1.1–4.9; P = 0.004). In FN with AE, hemoglobin was bimodally distributed with a dip around 85 g/L. There were no significant interactions for center, age and sex. In multivariate mixed logistic regression, AE was significantly and independently associated with leukopenia (leukocytes <0.3 G/L; OR, 3.3; 99%CI, 1.1–99; P = 0.004), dehydration (hemoglobinPresentation/hemoglobin8–72 hours ≥1.10 in untransfused patients; OR, 3.5; 99%CI, 1.1–11.4; P = 0.006) and non-moderate anemia (difference from 85 g/L; 1.6 per 10 g/L; 1.0–2.6; P = 0.005), but not with recent transfusion of packed red blood cells (pRBC), very recent transfusion of pRBC or platelets, or with hemoglobin ≥90 g/L as such. Conclusions Non-moderate anemia and dehydration were significantly and relevantly associated with the risk of AE in children with cancer and FN. These results need validation in prospective cohorts before clinical implementation.
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Affiliation(s)
- Roland A. Ammann
- Department of Pediatrics, University of Bern, Bern, Switzerland
- * E-mail:
| | - Felix K. Niggli
- Division of Oncology, Department of Pediatrics, University of Zurich, Zurich, Switzerland
| | - Kurt Leibundgut
- Department of Pediatrics, University of Bern, Bern, Switzerland
| | - Oliver Teuffel
- Department of Pediatrics, University of Bern, Bern, Switzerland
- Division of Oncology, Medical Services of the Statutory Health Insurance Baden-Württemberg, Tübingen, Germany
| | - Nicole Bodmer
- Division of Oncology, Department of Pediatrics, University of Zurich, Zurich, Switzerland
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An updated systematic review and meta-analysis of the predictive value of serum biomarkers in the assessment of fever during neutropenia in children with cancer. Pediatr Infect Dis J 2013; 32:e390-6. [PMID: 23673421 DOI: 10.1097/inf.0b013e31829ae38d] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Fever during neutropenia (FN) is a frequent and potentially life-threatening complication of the treatment of childhood cancer. The role of biomarkers in predicting morbidity and mortality associated with FN in children has been explored with varying results. This systematic review identified, critically appraised and synthesized information on the use of biomarkers for the prediction of outcome of FN in children/young adults, updating a review of initial assessment and adding further analysis of their value at reassessment. METHODS This review was conducted in accordance with the Centre for Reviews and Dissemination Methods, using 3 different random effects meta-analysis models. RESULTS Thirty-seven studies involving over 4689 episodes of FN in children were assessed, including an additional 13 studies investigating 18 biomarkers in 1670 FN episodes since the original review. Meta-analysis was possible for admission C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 and interleukin-8 in their ability to detect significant infection. Marked heterogeneity exists, precluding clear clinical interpretation of the results. Qualitative synthesis of the role of serial biomarkers suggests their predictive ability may be more pronounced at 24 to 48 hours compared with admission. Direct comparisons of the discriminatory power of admission values of PCT and CRP showed PCT generally had a better discriminatory estimate of serious infection than CRP. CONCLUSIONS There remains a paucity of robust and reproducible data on the use of biomarkers in prediction of serious infection in children with FN. Available evidence suggests PCT has better discriminatory ability than CRP and that the role of serial biomarkers warrants further study.
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Kitanovski L, Jazbec J, Hojker S, Derganc M. Diagnostic accuracy of lipopolysaccharide-binding protein for predicting bacteremia/clinical sepsis in children with febrile neutropenia: comparison with interleukin-6, procalcitonin, and C-reactive protein. Support Care Cancer 2013; 22:269-77. [PMID: 24057110 DOI: 10.1007/s00520-013-1978-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 09/11/2013] [Indexed: 12/31/2022]
Abstract
PURPOSE In febrile neutropenia (FN), no reliable marker has been identified to discriminate between severe infection and other causes of fever early in the clinical course. Since lipopolysaccharide-binding protein (LBP) has proven to be an accurate biomarker of bacteremia/clinical sepsis in critically ill non-immunocompromised infants and children, we performed a prospective study to determine the diagnostic accuracy of LBP in children with FN. METHODS Concentrations of LBP, procalcitonin (PCT), interleukin-6 (IL-6), and C-reactive protein (CRP) were prospectively measured on two consecutive days in 90 FN episodes experienced by 47 children. Receiver operating characteristic curve analysis was performed for each biomarker to predict bacteremia/clinical sepsis and severe sepsis. RESULTS Eighteen of the 90 episodes were classified as bacteremia/clinical sepsis. On both days 1 and 2, all biomarkers had a low to intermediate diagnostic accuracy for sepsis, and no significant differences were found between them (area under the curve (AUC) for LBP, 0.648 and 0.714; for PCT, 0.665 and 0.744; for IL-6, 0.775 and 0.775; and for CRP, 0.695 and 0.828). Comparison of their AUCs to the AUC of maximum body temperature on admission (AUC = 0.668) also failed to show any significant differences. In severe sepsis, however, the best diagnostic accuracies were found for IL-6 and PCT (AUC 0.892 and 0.752, respectively), and these were significantly higher than those for LBP (AUC 0.566) on admission. CONCLUSIONS On admission and 24 h later, the LBP concentration is less accurate for predicting bacteremia/clinical sepsis compared to IL-6, PCT, and CRP.
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Affiliation(s)
- Lidija Kitanovski
- Division of Hemato-Oncology, Department of Pediatrics, University Medical Center Ljubljana, Ljubljana, Slovenia,
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Castagnola E, Mikulska M, Barabino P, Lorenzi I, Haupt R, Viscoli C. Current research in empirical therapy for febrile neutropenia in cancer patients: what should be necessary and what is going on. Expert Opin Emerg Drugs 2013; 18:263-78. [DOI: 10.1517/14728214.2013.809419] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
INTRODUCTION Despite a low bacteremia rate, pediatric oncology patients are frequently admitted for febrile neutropenia. A pediatric risk prediction model with high sensitivity to identify patients at low risk for bacteremia is not available. We performed a single-institution prospective cohort study of pediatric oncology patients with febrile neutropenia to create a risk prediction model using clinical factors, respiratory viral infection, and cytokine expression. MATERIALS AND METHODS Pediatric oncology patients with febrile neutropenia were enrolled between March 30, 2010 and April 1, 2011 and managed per institutional protocol. Blood samples for C-reactive protein and cytokine expression and nasopharyngeal swabs for respiratory viral testing were obtained. Medical records were reviewed for clinical data. Statistical analysis utilized mixed multiple logistic regression modeling. RESULTS During the 12-month period, 195 febrile neutropenia episodes were enrolled. There were 24 (12%) episodes of bacteremia. Univariate analysis revealed several factors predictive for bacteremia, and interleukin (IL)-8 was the most predictive variable in the multivariate stepwise logistic regression. Low serum IL-8 predicted patients at low risk for bacteremia with a sensitivity of 0.9 and negative predictive value of 0.98. CONCLUSIONS IL-8 is a highly sensitive predictor for patients at low risk for bacteremia. IL-8 should be utilized in a multi-institution prospective trial to assign risk stratification to pediatric patients admitted with febrile neutropenia.
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Gibson F, Chisholm J, Blandford E, Donachie P, Hartley J, Lane S, Selwood K, Skinner R, Phillips R. Developing a national ‘low risk’ febrile neutropenia framework for use in children and young people's cancer care. Support Care Cancer 2012; 21:1241-51. [DOI: 10.1007/s00520-012-1653-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 10/29/2012] [Indexed: 11/24/2022]
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Lehrnbecher T, Phillips R, Alexander S, Alvaro F, Carlesse F, Fisher B, Hakim H, Santolaya M, Castagnola E, Davis BL, Dupuis LL, Gibson F, Groll AH, Gaur A, Gupta A, Kebudi R, Petrilli S, Steinbach WJ, Villarroel M, Zaoutis T, Sung L. Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation. J Clin Oncol 2012; 30:4427-38. [PMID: 22987086 DOI: 10.1200/jco.2012.42.7161] [Citation(s) in RCA: 240] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To develop an evidence-based guideline for the empiric management of pediatric fever and neutropenia (FN). METHODS The International Pediatric Fever and Neutropenia Guideline Panel is a multidisciplinary and multinational group composed of experts in pediatric oncology and infectious disease as well as a patient advocate. The Panel was convened for the purpose of creating this guideline. We followed previously validated procedures for creating evidence-based guidelines. Working groups focused on initial presentation, ongoing management, and empiric antifungal therapy. Each working group developed key clinical questions, conducted systematic reviews of the published literature, and compiled evidence summaries. The Grades of Recommendation Assessment, Development, and Evaluation approach was used to generate summaries, and evidence was classified as high, moderate, low, or very low based on methodologic considerations. RESULTS Recommendations were made related to initial presentation (risk stratification, initial evaluation, and treatment), ongoing management (modification and cessation of empiric antibiotics), and empiric antifungal treatment (risk stratification, evaluation, and treatment) of pediatric FN. For each recommendation, the strength of the recommendation and level of evidence are presented. CONCLUSION This guideline represents an evidence-based approach to FN specific to children with cancer. Although some recommendations are similar to adult-based guidelines, there are key distinctions in multiple areas. Implementation will require adaptation to the local context.
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Haeusler GM, Slavin MA. Complications of sepsis: the role of risk prediction rules, biomarkers and host genetics. Expert Rev Anti Infect Ther 2012; 10:733-5. [PMID: 22943396 DOI: 10.1586/eri.12.56] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The subtitle of the Australasian Society for Infectious Diseases Annual Scientific Meeting was 'Sailing into the Future', and speakers from both adult and pediatric infectious diseases explored this theme in relation to the management of sepsis. The future will entail better risk prediction tools for patients at risk for sepsis. Such risk prediction tools are likely to incorporate genetic profiling of the host to identify the groups at highest risk for disease and death. Focused diagnostic testing in these patients will include molecular diagnostics for early detection of infection.
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre and Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
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Brack E, Bodmer N, Simon A, Leibundgut K, Kühne T, Niggli FK, Ammann RA. First-day step-down to oral outpatient treatment versus continued standard treatment in children with cancer and low-risk fever in neutropenia. A randomized controlled trial within the multicenter SPOG 2003 FN study. Pediatr Blood Cancer 2012; 59:423-30. [PMID: 22271702 DOI: 10.1002/pbc.24076] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 12/21/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND The standard treatment of fever in chemotherapy-induced neutropenia (FN) includes emergency hospitalization and empirical intravenous antimicrobial therapy. This study determined if first-day step-down to oral outpatient treatment is not inferior to continued standard regarding safety and efficacy in children with low-risk FN. PROCEDURE In a randomized controlled non-blinded multicenter study, pediatric patients with FN after non-myeloablative chemotherapy were reassessed after 8-22 hours of inpatient intravenous antimicrobial therapy. Low-risk patients were randomized to first-day step-down to experimental (outpatient, oral amoxicillin plus ciprofloxacin) versus continued standard treatment. Exact non-inferiority tests were used for safety (no serious medical complication; non-inferiority margin of difference, 3.5%) and efficacy (resolution of infection without recurrence, no modification of antimicrobial therapy, no adverse event; 10%). RESULTS In 93 (26%) of 355 potentially eligible FN episodes low-risk criteria were fulfilled, and 62 were randomized, 28 to experimental (1 lost to follow-up) and 34 to standard treatment. In intention-to-treat analyses, non-inferiority was not proven for safety [27 of 27 (100%) vs. 33 of 34 (97%; 1 death) episodes; 95% upper confidence border, 6.7%; P = 0.11], but non-inferiority was proven for efficacy [23 of 27 (85%) vs. 26 of 34 (76%) episodes; 95% upper confidence border, 9.4%; P = 0.045]. Per-protocol analyses confirmed these results. CONCLUSIONS In children with low-risk FN, the efficacy of first-day step-down to oral antimicrobial therapy with amoxicillin and ciprofloxacin in an outpatient setting was non-inferior to continued hospitalization and intravenous antimicrobial therapy. The safety of this procedure, however, was not assessable with sufficient power.
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Affiliation(s)
- Eva Brack
- Department of Pediatrics, University of Bern, Bern, Switzerland
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Gavidia R, Fuentes SL, Vasquez R, Bonilla M, Ethier MC, Diorio C, Caniza M, Howard SC, Sung L. Low socioeconomic status is associated with prolonged times to assessment and treatment, sepsis and infectious death in pediatric fever in El Salvador. PLoS One 2012; 7:e43639. [PMID: 22928008 PMCID: PMC3425537 DOI: 10.1371/journal.pone.0043639] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 07/23/2012] [Indexed: 11/18/2022] Open
Abstract
Background Infection remains the most common cause of death from toxicity in children with cancer in low- and middle-income countries. Rapid administration of antibiotics when fever develops can prevent progression to sepsis and shock, and serves as an important indicator of the quality of care in children with acute lymphoblastic leukemia and acute myeloid leukemia. We analyzed factors associated with (1) Longer times from fever onset to hospital presentation/antibiotic treatment and (2) Sepsis and infection-related mortality. Method This prospective cohort study included children aged 0–16 years with newly diagnosed acute leukemia treated at Benjamin Bloom Hospital, San Salvador. We interviewed parents/caregivers within one month of diagnosis and at the onset of each new febrile episode. Times from initial fever to first antibiotic administration and occurrence of sepsis and infection-related mortality were documented. Findings Of 251 children enrolled, 215 had acute lymphoblastic leukemia (85.7%). Among 269 outpatient febrile episodes, median times from fever to deciding to seek medical care was 10.0 hours (interquartile range [IQR] 5.0–20.0), and from decision to seek care to first hospital visit was 1.8 hours (IQR 1.0–3.0). Forty-seven (17.5%) patients developed sepsis and 7 (2.6%) died of infection. Maternal illiteracy was associated with longer time from fever to decision to seek care (P = 0.029) and sepsis (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.09–8.63; P = 0.034). More infectious deaths occurred in those with longer travel time to hospital (OR 1.36, 95% CI 1.03–1.81; P = 0.031) and in families with an annual household income <US$2,000 (OR 13.90, 95% CI 1.62–119.10; P = 0.016). Interpretation Illiteracy, poverty, and longer travel times are associated with delays in assessment and treatment of fever and with sepsis and infectious mortality in pediatric leukemia. Providing additional education to high-risk families and staying at a nearby guest house during periods of neutropenia may decrease sepsis and infectious mortality.
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Affiliation(s)
- Ronald Gavidia
- Pediatric Oncology, Benjamin Bloom National Children’s Hospital, San Salvador, El Salvador
| | - Soad L. Fuentes
- Pediatric Oncology, Benjamin Bloom National Children’s Hospital, San Salvador, El Salvador
| | - Roberto Vasquez
- Pediatric Oncology, Benjamin Bloom National Children’s Hospital, San Salvador, El Salvador
| | - Miguel Bonilla
- Pediatric Oncology, Benjamin Bloom National Children’s Hospital, San Salvador, El Salvador
| | - Marie-Chantal Ethier
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
| | - Caroline Diorio
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
| | - Miguela Caniza
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, United States of America
- International Outreach Program, St. Jude Children's Research Hospital, Memphis, Tennessee, United States of America
| | - Scott C. Howard
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, United States of America
- International Outreach Program, St. Jude Children's Research Hospital, Memphis, Tennessee, United States of America
| | - Lillian Sung
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- * E-mail:
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Phillips B, Wade R, Westwood M, Riley R, Sutton AJ. Systematic review and meta-analysis of the value of clinical features to exclude radiographic pneumonia in febrile neutropenic episodes in children and young people. J Paediatr Child Health 2012; 48:641-8. [PMID: 22050289 DOI: 10.1111/j.1440-1754.2011.02211.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Children and young people who present with febrile neutropenia (FNP) secondary to malignancies or their treatment frequently do not undergo routine chest radiography. With shorter courses of antibiotic therapy, failure to recognise pneumonia and consequent under-treatment could produce significant problems. METHODS The review was conducted determine the value of the absence of clinical features of lower respiratory tract infection in excluding radiographic pneumonia at presentation of FNP using Centre for Reviews and Dissemination methods. It was registered with the HTA Registry of systematic reviews, CRD32009100453. Ten bibliographic databases, conference proceedings, reference lists and citations were searched. Cohort studies which compared clinical examination to radiographic findings were included. Results were summarised by random-effects meta-analysis. RESULTS Four studies were included. Synthesis of the three higher-quality studies gave imprecise estimates of the average sensitivity (75%; 95% CI 52% to 89%) and average specificity (69%; 95% CI 57% to 78%) for clinical examination in the detection of radiographic pneumonia. If the prevalence of pneumonia is 5%, these estimates produce a negative predictive value of 98% (95% CI 96% to 99%). Alternatively, there remains a 1.9% probability of pneumonia (95% CI 0.7% to 4.2%). CONCLUSION Signs and symptoms of lower respiratory infection have only moderate sensitivity and specificity for pneumonia; the low prevalence of the condition justifies the routine withholding of chest radiographs. However, for those with a predisposition to pneumonia, or re-presenting after a short course of antibiotic therapy, a chest X-ray should be performed despite an absence of signs.
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Affiliation(s)
- Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, UK.
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Phillips RS, Lehrnbecher T, Alexander S, Sung L. Updated systematic review and meta-analysis of the performance of risk prediction rules in children and young people with febrile neutropenia. PLoS One 2012; 7:e38300. [PMID: 22693615 PMCID: PMC3365042 DOI: 10.1371/journal.pone.0038300] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 05/03/2012] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Febrile neutropenia is a common and potentially life-threatening complication of treatment for childhood cancer, which has increasingly been subject to targeted treatment based on clinical risk stratification. Our previous meta-analysis demonstrated 16 rules had been described and 2 of them subject to validation in more than one study. We aimed to advance our knowledge of evidence on the discriminatory ability and predictive accuracy of such risk stratification clinical decision rules (CDR) for children and young people with cancer by updating our systematic review. METHODS The review was conducted in accordance with Centre for Reviews and Dissemination methods, searching multiple electronic databases, using two independent reviewers, formal critical appraisal with QUADAS and meta-analysis with random effects models where appropriate. It was registered with PROSPERO: CRD42011001685. RESULTS We found 9 new publications describing a further 7 new CDR, and validations of 7 rules. Six CDR have now been subject to testing across more than two data sets. Most validations demonstrated the rule to be less efficient than when initially proposed; geographical differences appeared to be one explanation for this. CONCLUSION The use of clinical decision rules will require local validation before widespread use. Considerable uncertainty remains over the most effective rule to use in each population, and an ongoing individual-patient-data meta-analysis should develop and test a more reliable CDR to improve stratification and optimise therapy. Despite current challenges, we believe it will be possible to define an internationally effective CDR to harmonise the treatment of children with febrile neutropenia.
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Affiliation(s)
- Robert S Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom.
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Manji A, Beyene J, Dupuis LL, Phillips R, Lehrnbecher T, Sung L. Outpatient and oral antibiotic management of low-risk febrile neutropenia are effective in children--a systematic review of prospective trials. Support Care Cancer 2012; 20:1135-45. [PMID: 22402749 DOI: 10.1007/s00520-012-1425-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 02/21/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is no consensus on whether therapeutic intensity can be reduced safely in children with low-risk febrile neutropenia (FN). Our primary objective was to determine whether there is a difference in efficacy between outpatient and inpatient management of children with low-risk FN. Our secondary objective was to compare oral and parenteral antibiotic therapy in this population. METHODS We performed electronic searches of Ovid Medline, EMBASE, and the Cochrane Central Register of Controlled Trials, and limited studies to prospective pediatric trials in low-risk FN. Percentages were used as the effect measure. RESULTS From 7,281 reviewed articles, 16 were included in the meta-analysis. Treatment failure, including antibiotic modification, was less likely to occur in the outpatient setting compared with the inpatient setting (15 % versus 28 %, P = 0.04) but was not significantly different between oral and parenteral antibiotic regimens (20 % versus 22 %, P = 0.68). Of the 953 episodes treated in the outpatient setting and 676 episodes treated with oral antibiotics, none were associated with infection-related mortality. CONCLUSION Based on the combination of results from all prospective studies to date, outpatient and oral antibiotic management of low-risk FN are effective in children and should be incorporated into clinical care where feasible.
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Affiliation(s)
- A Manji
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada
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Phillips RS, Sutton AJ, Riley RD, Chisholm JC, Picton SV, Stewart LA. Predicting infectious complications in neutropenic children and young people with cancer (IPD protocol). Syst Rev 2012; 1:8. [PMID: 22588015 PMCID: PMC3351734 DOI: 10.1186/2046-4053-1-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Accepted: 02/09/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A common and potentially life-threatening complication of the treatment of childhood cancer is infection, which frequently presents as fever with neutropenia. The standard management of such episodes is the extensive use of intravenous antibiotics, and though it produces excellent survival rates of over 95%, it greatly inconveniences the three-fourths of patients who do not require such aggressive treatment. There have been a number of studies which have aimed to develop risk prediction models to stratify treatment. Individual participant data (IPD) meta-analysis in therapeutic studies has been developed to improve the precision and reliability of answers to questions of treatment effect and recently have been suggested to be used to answer questions regarding prognosis and diagnosis to gain greater power from the frequently small individual studies. DESIGN In the IPD protocol, we will collect and synthesise IPD from multiple studies and examine the outcomes of episodes of febrile neutropenia as a consequence of their treatment for malignant disease. We will develop and evaluate a risk stratification model using hierarchical regression models to stratify patients by their risk of experiencing adverse outcomes during an episode. We will also explore specific practical and methodological issues regarding adaptation of established techniques of IPD meta-analysis of interventions for use in synthesising evidence derived from IPD from multiple studies for use in predictive modelling contexts. DISCUSSION Our aim in using this model is to define a group of individuals at low risk for febrile neutropenia who might be treated with reduced intensity or duration of antibiotic therapy and so reduce the inconvenience and cost of these episodes, as well as to define a group of patients at very high risk of complications who could be subject to more intensive therapies. The project will also help develop methods of IPD predictive modelling for use in future studies of risk prediction.
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Affiliation(s)
- Robert S Phillips
- Centre for Reviews and Dissemination, Alcuin College, University of York, York, YO10 5DD, UK.
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Abstract
PURPOSE OF REVIEW To describe and discuss the most recent advances in the management of low-risk febrile neutropenia in children with cancer. RECENT FINDINGS Several risk stratification tools for children with febrile neutropenia have been developed, although none of these tools have been directly compared and few have been validated in independent populations. However, there is good evidence that, for pediatric patients with febrile neutropenia at low risk for severe infection, outpatient management is a well tolerated and efficacious alternative to inpatient care. Moreover, major progress has been made in obtaining and understanding perceived quality of life and preferences for outpatient management in pediatric cancer patients. Many parents prefer inpatient management although child quality of life is, in general, anticipated to be higher with outpatient intravenous therapy. Finally, outpatient strategies are more cost-effective as compared with traditional management in hospital. SUMMARY Outpatient management is a well tolerated and cost-effective strategy for low-risk febrile neutropenia in children with cancer, although parental preferences are highly variable for outpatient versus inpatient management. Future research should examine the effectiveness of outpatient strategies through conduct of large cohort studies. Other future work could focus on development of decision aids and other tools to facilitate ambulatory approaches.
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Phillips RS, Wade R, Lehrnbecher T, Stewart LA, Sutton AJ. Systematic review and meta-analysis of the value of initial biomarkers in predicting adverse outcome in febrile neutropenic episodes in children and young people with cancer. BMC Med 2012; 10:6. [PMID: 22257704 PMCID: PMC3331823 DOI: 10.1186/1741-7015-10-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 01/18/2012] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Febrile neutropenia is a frequently occurring and occasionally life-threatening complication of treatment for childhood cancer. Many biomarkers have been proposed as predictors of adverse events. We aimed to undertake a systematic review and meta-analysis to summarize evidence on the discriminatory ability of initial serum biomarkers of febrile neutropenic episodes in children and young people. METHODS This review was conducted in accordance with the Center for Reviews and Dissemination Methods, using three random effects models to undertake meta-analysis. It was registered with the HTA Registry of systematic reviews, CRD32009100485. RESULTS We found that 25 studies exploring 14 different biomarkers were assessed in 3,585 episodes of febrile neutropenia. C-reactive protein (CRP), pro-calcitonin (PCT), and interleukin-6 (IL6) were subject to quantitative meta-analysis, and revealed huge inconsistencies and heterogeneity in the studies included in this review. Only CRP has been evaluated in assessing its value over the predictive value of simple clinical decision rules. CONCLUSIONS The limited data available describing the predictive value of biomarkers in the setting of pediatric febrile neutropenia mean firm conclusions cannot yet be reached, although the use of IL6, IL8 and procalcitonin warrant further study.
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Predicting the risk of severe infection in children with chemotherapy-induced febrile neutropenia. Curr Opin Hematol 2012; 19:39-43. [DOI: 10.1097/moh.0b013e32834da951] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sung L. Initial Management of Low-Risk Pediatric Fever and Neutropenia: Efficacy and Safety, Costs, Quality-of-Life Considerations, and Preferences. Am Soc Clin Oncol Educ Book 2012:570-574. [PMID: 24451798 DOI: 10.14694/edbook_am.2012.32.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Initial management options for pediatric low-risk fever and neutropenia (FN) include outpatient compared with inpatient management and oral compared with intravenous therapy. Single-arm and randomized trials have been conducted in children. Meta-analyses provide support for the equivalence of outpatient and inpatient approaches. Outpatient oral management may be associated with a higher risk of readmission compared with outpatient intravenous management in children with FN, although other outcomes such as treatment failure and discontinuation of the regimen because of adverse effects were similar. Importantly, there have been no reported deaths among low-risk children treated as outpatients or with oral antibiotics. Costs, whether derived directly or through cost-effectiveness analysis, are consistently reduced when an outpatient approach is used. Quality of life (QoL) and preferences should be considered in order to evaluate different strategies, plan programs, and anticipate uptake of outpatient programs. Using parent-proxy report, child QoL is consistently higher with outpatient approaches, although research evaluating child self-report is limited. Preferences incorporate estimated QoL, but, in addition, factor in issues such as costs, fear, anxiety, and logistical issues. Only approximately 50% of parents prefer outpatient management. Future research should develop tools to facilitate outpatient care and to measure caregiver burden associated with this strategy. Additional work should also focus on eliciting child preferences for outpatient management. Finally, studies of effectiveness of an ambulatory approach in the real-world setting outside of clinical trials are important.
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Affiliation(s)
- Lillian Sung
- From the Division of Haematology/Oncology, and Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
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Hakim H, Gaur AH. Initial Management of Fever and Neutropenia in a Child With Cancer—The Past, the Present, and the Future. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2011. [DOI: 10.1016/j.cpem.2011.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Sung L, Phillips R, Lehrnbecher T. Time for paediatric febrile neutropenia guidelines – children are not little adults. Eur J Cancer 2011; 47:811-3. [DOI: 10.1016/j.ejca.2011.01.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 01/28/2011] [Indexed: 10/18/2022]
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Alves BE, Montalvao SAL, Aranha FJP, Lorand-Metze I, De Souza CA, Annichino-Bizzacchi JM, De Paula EV. Time-course of sFlt-1 and VEGF-A release in neutropenic patients with sepsis and septic shock: a prospective study. J Transl Med 2011; 9:23. [PMID: 21371321 PMCID: PMC3058017 DOI: 10.1186/1479-5876-9-23] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Accepted: 03/03/2011] [Indexed: 11/24/2022] Open
Abstract
Background Septic shock is the most feared complication of chemotherapy-induced febrile neutropenia. So far, there are no robust biomarkers that can stratify patients to the risk of sepsis complications. The VEGF-A axis is involved in the control of microvascular permeability and has been involved in the pathogenesis of conditions associated with endothelial barrier disruption such as sepsis. sFlt-1 is a soluble variant of the VEGF-A receptor VEGFR-1 that acts as a decoy receptor down-regulating the effects of VEGF-A. In animal models of sepsis, sFlt-1 was capable to block the barrier-breaking negative effects of VEGF-A and to significantly decrease mortality. In non-neutropenic patients, sFlt-1 has been shown to be a promising biomarker for sepsis severity. Methods We prospectively evaluated concentrations of sFlt-1 and VEGF-A at different time-points during febrile neutropenia, and evaluated the association of these levels with sepsis severity and septic shock development. Results Neutropenic patients that evolved with septic shock (n = 10) presented higher levels of sFlt-1 and VEGF-A measured 48 hours after fever onset than patients with non-complicated sepsis (n = 31) and levels of these biomarkers correlated with sepsis severity scores. Estimation of the diagnostic accuracy of sFlt-1 levels for the discrimination of patients that evolved to septic shock yielded promising results in our study population. Discussion Our data suggest that sFlt-1 and VEGF-A could be useful biomarkers for sepsis severity in patients with febrile neutropenia. In addition, the kinetics of sFlt-1 release in patients that evolve to septic shock suggest that the sFlt-1 could be a salvage compensatory mechanism in patients with septic shock, but that the magnitude of the sFlt-1 release observed in human sepsis is not sufficient to reproduce the beneficial anti-VEGF-A effects observed in animal models of sepsis.
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Affiliation(s)
- Brunna E Alves
- Hematology and Hemotherapy Center, University of Campinas, Campinas, SP, Brazil
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