1
|
Torres JP, Santolaya ME. Respiratory viral infections in children with cancer and febrile neutropenia and children undergoing hematopoietic stem cell transplantation. Curr Opin Infect Dis 2024; 37:407-412. [PMID: 39106082 DOI: 10.1097/qco.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
PURPOSE OF REVIEW The scope of this review is to understand the epidemiology and potential role of respiratory viral infections in children with cancer and febrile neutropenia, as well as in children, undergoing hematopoietic stem cell transplantation. Early detection of respiratory viral infections through molecular diagnostic techniques has allowed recent randomized clinical studies to advance the possibility of more rational use of antimicrobials in this susceptible population. RECENT FINDINGS Progress has been made in the early detection of respiratory viruses in episodes of fever and neutropenia in children with cancer. In selected patients who meet specific clinical safety criteria and have negative bacterial cultures, it has been possible to safely and effectively discontinue antimicrobials. This has been validated in recent randomized clinical studies. However, more evidence is still needed for a similar indication in children, undergoing hematopoietic stem cell transplantation with viral respiratory infection episodes. SUMMARY Understanding the role of respiratory viral infections in populations of immunocompromised children may contribute to a more rational use of antimicrobials and, in the near future, may help to decrease antimicrobial resistance in this susceptible population.
Collapse
Affiliation(s)
- Juan P Torres
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Hospital Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | | |
Collapse
|
2
|
Torres JP, Ibañez C, Valenzuela R, Rivera S, De la Maza V, Villarroel M, Coria P, Contardo V, Álvarez AM, Zubieta CM, Gutierrez V, Ducasse K, Martínez D, Santolaya ME. Efficacy and safety of withholding antimicrobial therapy in children with cancer, fever, and neutropenia, with a demonstrated viral respiratory infection: a randomized clinical trial. Clin Microbiol Infect 2024; 30:1029-1034. [PMID: 38648896 DOI: 10.1016/j.cmi.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 04/03/2024] [Accepted: 04/13/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVES To validate the efficacy and safety of withholding antimicrobial therapy in a new cohort of children with cancer and febrile neutropenia (FN) having a demonstrated viral respiratory tract infection. METHODS Prospective, multicenter, noninferiority, randomized study, approved by the ethical committee, in children presenting with FN at seven hospitals in Chile, evaluated at admission for diagnosis of bacterial and viral pathogens. Children who were positive for a respiratory virus, negative for a bacterial pathogen, and had a favourable evolution after 48-72 hours of antimicrobial therapy were randomized to either maintain or withhold antimicrobial therapy. The primary endpoint was the percentage of episodes with an uneventful resolution, whereas the secondary endpoints were days of fever, days of hospitalization, requirement of antimicrobial treatment readministration, sepsis, paediatric intensive care unit admission, and death. RESULTS A total of 301 of 939 children with FN episodes recruited between March 2021 and December 2023 had a respiratory virus as a unique identified microorganism, of which 139 had a favourable evolution at 48-72 hours and were randomized, 70 to maintain and 69 to withdraw antimicrobial therapy. The median days of antimicrobial therapy was 5 (IQR 3-6) versus 3 (IQR 3-6) days (p < 0.001), with similar frequency of uneventful resolution 66/70 (94%) and 66/69 (96%); relative risk, 1.01; (95% CI, 0.93 to 1.09), absolute risk difference 0.01; (95% CI, -0.05 to 0.08) and similar number of days of fever and days of hospitalization. No cases of sepsis, paediatric intensive care unit admission, or death were reported. DISCUSSION We validated the strategy of withdrawal antimicrobial therapy in children with FN and viral respiratory tract infection based on clinical and microbiological/molecular diagnostic criteria. This will enable advances in antimicrobial stewardship strategies with a possible future impact on antimicrobial resistance.
Collapse
Affiliation(s)
- Juan P Torres
- Department of Paediatrics, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Program of Antineoplastics Drugs Network (PINDA), Chile
| | - Carolina Ibañez
- Department of Paediatrics, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Romina Valenzuela
- Research Unit, Department of Paediatrics, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Salome Rivera
- Research Unit, Department of Paediatrics, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Veronica De la Maza
- Research Unit, Department of Paediatrics, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Milena Villarroel
- Department of Paediatrics, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Program of Antineoplastics Drugs Network (PINDA), Chile
| | - Paulina Coria
- Department of Paediatrics, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Veronica Contardo
- Department of Paediatrics, Hospital Dr. Roberto del Rio, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Program of Antineoplastics Drugs Network (PINDA), Chile
| | - Ana M Álvarez
- Department of Paediatrics, Hospital San Juan de Dios, Santiago, Chile; Committee of Infectious Diseases, National Child Program of Antineoplastics Drugs Network (PINDA), Chile
| | - Carmen M Zubieta
- Department of Paediatrics, Hospital Dr. Exequiel González Cortés, Santiago, Chile
| | - Valentina Gutierrez
- Department of Paediatrics, Hospital Dr. Sótero del Río, Santiago, Chile; Committee of Infectious Diseases, National Child Program of Antineoplastics Drugs Network (PINDA), Chile
| | - Karen Ducasse
- Department of Paediatrics, Hospital Gustavo Fricke, Viña del Mar, Chile; Committee of Infectious Diseases, National Child Program of Antineoplastics Drugs Network (PINDA), Chile
| | - Daniela Martínez
- Department of Paediatrics, Hospital San Borja Arriarán, Santiago, Chile; Committee of Infectious Diseases, National Child Program of Antineoplastics Drugs Network (PINDA), Chile
| | - Maria E Santolaya
- Department of Paediatrics, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Program of Antineoplastics Drugs Network (PINDA), Chile.
| |
Collapse
|
3
|
Clément L, Hélène D, Maud M, Chrystelle D, Constance B, Fréderic M, France R, Pilar GHM, José-Miguel TD, Blandine R. Safety of empirical antibiotic therapy discontinuing for fever of unknown origin during high-risk neutropenia in children. J Infect 2024; 88:106171. [PMID: 38697268 DOI: 10.1016/j.jinf.2024.106171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND ECIL-2021 recommends discontinuing empirical antibiotic therapy (EAT) in febrile-neutropenic children after 72 h of treatment and at least 24-48 h of apyrexia in the case of fever of unknown origin (FUO). These guidelines are rarely applied to high-risk children's neutropenia. MATERIAL AND METHODS We retrospectively included all consecutive FUO episodes occurring during profound neutropenia ≥ 10 days in children in our institution. We evaluated the safety of EAT discontinuation in patients for whom the ECIL guidelines were followed compared to those for whom they didn't. We used a combined criterion of mortality and intensive care unit admission at 30 days. We identified risk factors for recurrent fever after EAT discontinuation. RESULTS Fifty-one FUO episodes occurred in 37 patients. EAT discontinuation followed ECIL guidelines in 19 (37 %) episodes. No deaths and-or transfers in ICU occurred in the ECIL group. The duration of EAT was shorter by nine days in the group following ECIL guidelines (p < 0.001). We observed 14 (27 %) episodes of recurrent fever. Mucositis was significantly associated with recurrent fever (p < 0.01). CONCLUSION EAT discontinuation seems feasible and safe in FUO during prolonged febrile neutropenia in children. However, mucosal lesions should prompt thorough surveillance due to the risk of recurrent fever.
Collapse
Affiliation(s)
- Lemaigre Clément
- CHU Poitiers, Service de Maladies Infectieuses et Tropicales, Poitiers, France; Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France
| | - Deutch Hélène
- Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | - Meligne Maud
- Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | - Dupraz Chrystelle
- Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | | | - Millot Fréderic
- Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; Service de Pédiatrie, CHU Poitiers, Poitiers, France
| | - Roblot France
- CHU Poitiers, Service de Maladies Infectieuses et Tropicales, Poitiers, France; Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; INSERM U1070, Poitiers, France
| | - Gallego-Hernanz Maria Pilar
- Service d'Oncologie Hématologique Et Thérapie Cellulaire, INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, 86021 Poitiers Cedex, France
| | - Torregrosa-Diaz José-Miguel
- Service d'Oncologie Hématologique Et Thérapie Cellulaire, INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, 86021 Poitiers Cedex, France
| | - Rammaert Blandine
- CHU Poitiers, Service de Maladies Infectieuses et Tropicales, Poitiers, France; Université de Poitiers, Faculté de médecine et pharmacie, Poitiers, France; INSERM U1070, Poitiers, France.
| |
Collapse
|
4
|
Patel PA, Teherani MF, Xiang Y, Bernardo V, Chandrakasan S, Goggin KP, Haight A, Horwitz E, Liang WH, Parikh SH, Schoettler ML, Spencer K, Stenger E, Watkins B, Williams KM, Leung K, Jaggi P, Qayed M. Short-Course Empiric Antibiotics in Children Undergoing Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:778.e1-778.e6. [PMID: 37739225 DOI: 10.1016/j.jtct.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/24/2023]
Abstract
Fever is common in children undergoing hematopoietic cell transplantation (HCT). Empiric antibiotic (EA) therapy is initiated and often continued until neutrophil engraftment. Prolonged antibiotic exposure reduces microbiome diversity and causes overgrowth of pathogenic organisms, leading to such complications as infections from antibiotic-resistant organisms and Clostridium difficile colitis. Shorter courses of EA therapy have been studied in adults undergoing HCT without significant safety concerns, but data in children are lacking. We instituted a single-center preintervention/ postintervention quality improvement (QI) project to assess the feasibility of short-course EA therapy for first fever in patients undergoing HCT. We aimed to reduce the median duration of broad-spectrum antibiotic use in eligible patients from 20 days in 2020 to 10 days in 2021. Patients were eligible for the intervention, limiting EAs to 7 days for first fever, if they were admitted for their first allogeneic HCT, were afebrile for >24 hours, had no infection requiring systemic treatment, and were hemodynamically stable. Outcome measures included days of EA therapy for first fever and total broad-spectrum antibiotic use during the period of hospitalization, defined as the time from the start of conditioning to 30 days after HCT or hospital discharge, whichever occurred first. Balancing measures included bloodstream infection (BSI), fever, and intensive care (ICU) admission within 3 days of stopping EA therapy. Project criteria were applied retrospectively to patients who underwent HCT in 2020 to construct a preintervention short-course-eligible cohort. During the intervention period, 41 patients underwent allogeneic HCT, of whom 17 (41%) were eligible for short-course EA therapy. Among eligible patients, the median age was 5.3 years, 47% had an underlying malignancy, and 88% received myeloablative conditioning. There were no differences in demographic or HCT characteristics between patients eligible for short-course EA during the intervention and preintervention period (n = 24). The short-course EA schedule was adhered to by 14 of the 17 eligible patients (82%). The duration of EA for first fever and total broad-spectrum antibiotic use was significantly decreased in the short-course EA-eligible patients compared to the preintervention cohort, from a median of 17 days to 8 days and from 20 days to 10 days, respectively (P < .01). Of the 14 patients adhering to short-course EA, 2 experienced a balancing measure of recurrent fever requiring resumption of EA, but no infection was identified. There were no BSIs, ICU admissions, or deaths during the hospitalization period in patients who received short-course EA. In this single-center QI project, short-course EA for initial fever was successfully applied to children undergoing allogeneic HCT using strict criteria and led to a significant decrease in broad-spectrum antibiotic use during hospitalization. These results should be validated in a prospective clinical trial to include the impact of short-course EA on antibiotic-resistant organisms, the intestinal microbiome, and HCT outcomes.
Collapse
Affiliation(s)
- Pratik A Patel
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia; Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia.
| | - Mehgan F Teherani
- Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yijin Xiang
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | | | - Shanmuganathan Chandrakasan
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kathryn P Goggin
- Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia
| | - Ann Haight
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Edwin Horwitz
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Wayne H Liang
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Suhag H Parikh
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Michelle L Schoettler
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | | | - Elizabeth Stenger
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Benjamin Watkins
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kirsten M Williams
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kathryn Leung
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Preeti Jaggi
- Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia
| | - Muna Qayed
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| |
Collapse
|
5
|
Vargas C, Haeusler GM, Slavin MA, Babl FE, Mechinaud F, Phillips R, Thursky K, Lourenco RDA. An analysis of the resource use and costs of febrile neutropenia events in pediatric cancer patients in Australia. Pediatr Blood Cancer 2023; 70:e30633. [PMID: 37592047 DOI: 10.1002/pbc.30633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/31/2023] [Accepted: 08/05/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Febrile neutropenia (FN) in children with cancer generally requires in-hospital care, but low-risk patients may be successfully managed in an outpatient setting, potentially reducing the overall healthcare costs. Updated data on the costs of FN care are lacking. METHODS A bottom-up microcosting analysis was conducted from the healthcare system perspective using data collected alongside the Australian PICNICC (Predicting Infectious Complications of Neutropenic sepsis In Children with Cancer) study. Inpatient costs were accessed from hospital administrative records and outpatient costs from Medicare data. Costs were stratified by risk status (low/high risk) according to the PICNICC criteria. Estimated mean costs were obtained through bootstrapping and using a linear model to account for multiple events across individuals and other clinical factors that may impact costs. RESULTS The total costs of FN care were significantly higher for FN events classified as high-risk ($17,827, 95% confidence interval [CI]: $17,193-$18,461) compared to low-risk ($10,574, 95% CI: $9818-$11,330). In-hospital costs were significantly higher for high-risk compared to low-risk events, despite no differences in the cost structure, mean cost per day, and pattern of resource use. Hospital length of stay (LOS) was the only modifiable factor significantly associated with total costs of care. Excluding antineoplastics, antimicrobials are the most commonly used medications in the inpatient and outpatient setting for the overall period of analysis. CONCLUSION The FN costs are driven by in-hospital admission and LOS. This suggests that the outpatient management of low-risk patients is likely to reduce the in-hospital cost of treating an FN event. Further research will determine if shifting the cost to the outpatient setting remains cost-effective overall.
Collapse
Affiliation(s)
- Constanza Vargas
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Broadway, New South Wales, Australia
| | - 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, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- The Paediatric Integrated Cancer Service, Victoria State Government, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, 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, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Francoise Mechinaud
- Unité d'hématologie Immunologie Pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, Paris, France
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, UK
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK
| | - Karin 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, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Broadway, New South Wales, Australia
| |
Collapse
|
6
|
De Pietri S, Weischendorff S, Rathe M, Frandsen TL, Hasle H, Nersting J, Nielsen CH, Moser C, Müller K. Gastrointestinal barrier integrity and mucosal inflammation as risk factors of blood stream infections in children treated for acute lymphoblastic leukaemia. Int J Cancer 2023; 153:1635-1642. [PMID: 37387257 DOI: 10.1002/ijc.34639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/08/2023] [Accepted: 06/14/2023] [Indexed: 07/01/2023]
Abstract
Chemotherapy-induced mucositis increases the risk of blood stream infections (BSI) due to translocation of bacteria across the intestinal epithelium. Our study investigated if quantitative measures of intestinal mucositis severity, including plasma citrulline (a marker of functional enterocytes) and CCL20 (an intestinal immune homeostatic chemokine), could identify patients at risk of BSI. A total of 106 children with ALL undergoing induction treatment (NOPHO ALL 2008) were included and information regarding BSI episodes was collected from the patients' medical records. Twenty-seven patients (25%) developed BSI during induction. Patients with BSI had a larger decrease in citrulline after chemotherapy than patients without BSI, and nearly all BSI episodes (25/27) occurred in the group of patients exhibiting a drop in citrulline (OR = 6.4 [95% CI: 1.4-29.3], P = .008). Patients who developed BSI had higher plasma CCL20 levels on days 8, 15 and 22 than patients without BSI (all P < .05), and elevated CCL20 levels on day 8 increased the risk of subsequent BSI (OR = 1.57 [1.11-2.22] per doubling of CCL20 level, P = .01) in a multivariable logistic regression analysis. These findings suggest that children with ALL who develop BSI during chemotherapy are characterised by more severe intestinal mucositis, as measured by plasma citrulline and CCL20. These markers may be useful in early risk stratification to guide treatment decisions.
Collapse
Affiliation(s)
- Silvia De Pietri
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sarah Weischendorff
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mathias Rathe
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Thomas Leth Frandsen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jacob Nersting
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Claus H Nielsen
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Klaus Müller
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Institute for Inflammation Research, Center for Rheumatology and Spine Disease, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Mackie DB, Kuo D, Paul M, Elster J. Does Fever Response to Acetaminophen Predict Bloodstream Infections in Febrile Neutropenia? Cureus 2023; 15:e36712. [PMID: 37113346 PMCID: PMC10129031 DOI: 10.7759/cureus.36712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 03/28/2023] Open
Abstract
BACKGROUND There is a need to identify clinical parameters for early and effective risk stratification and prediction of bacterial bloodstream infections (BSIs) in patients with febrile neutropenia (FN). Acetaminophen is used widely to treat fever in FN; however, little research exists on whether fever response to acetaminophen can be used as a predictor of BSIs. OBJECTIVES Investigate the relationship between fever response to acetaminophen and bacteremia in FN. DESIGN/METHOD A retrospective review of patients (1-21 years old) presenting with FN and bacteremia at Rady Children's Hospital (2012-2018) was performed. Demographic information, presenting signs/symptoms, degree of neutropenia (absolute neutrophil count (ANC) > 500 or < 500 cells/µL), absolute monocyte count, blood culture results, temperatures one, two, and six hours after acetaminophen, and timing of antibiotic administration were examined. Patients were stratified into three malignancy categories: leukemia/lymphoma, solid tumor, and hematopoietic stem cell transplant. Patients were matched with culture-negative controls based on sex, age, malignancy category, and degree of neutropenia. RESULTS Thirty-five case-control pairs met inclusion criteria (70 presentations of FN). The mean age of the cases was 10.7 years (± 6.3) vs. 10.0 years (± 5.9) for the controls. Twenty were female (57%). Twenty-three pairs were categorized as leukemia/lymphoma (66%), eight as solid tumors (23%), and four as HSCT (11%). Thirty-four pairs (97%) had a presenting ANC < 500 cells/µL. Higher temperature one-hour post-acetaminophen was associated with bacteremia (p = 0.04). Logistic regression demonstrated that temperature one-hour post-acetaminophen had a significant predictive value for bacteremia (p = 0.011). The area under the receiver operating characteristic curves for logistic regression and classification and regression tree analysis were 0.70 and 0.71, respectively. CONCLUSION While temperature one-hour post-acetaminophen was higher among patients with bacteremia and was a significant predictor of bacteremia, fever response in isolation lacks sufficient predictive value to impact clinical decision-making. Future studies are needed to assess fever responsiveness as an adjunct to existing modalities of FN risk stratification.
Collapse
|
9
|
Nessle CN, Braun T, Choi SW, Mody R. Internal evaluation of risk stratification tool using serial procalcitonin and clinical risk factors in pediatric febrile neutropenia: The non-interventional, single institution experience prior to clinical implementation. Pediatr Hematol Oncol 2023; 40:172-180. [PMID: 35838022 PMCID: PMC9840714 DOI: 10.1080/08880018.2022.2079785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Risk stratification of pediatric febrile neutropenia (FN) is an established concept, yet clinical risk tools misclassify nearly 5% of clinical standard-risk episodes with severe outcomes. The internal evaluation of a clinical risk tool before implementation has not been well-described. In this noninterventional cohort study, we evaluated a study decision rules (SDR) tool; a clinical risk tool with serial procalcitonin. The study standard-risk (SSR) group met clinical standard-risk criteria with two serial procalcitonin <0.4 ng/mL. The study high-risk (SHR) group met clinical high-risk criteria or clinical standard-risk with a procalcitonin ≥0.4 ng/mL. Descriptive and bivariate statistics compared the groups and outcomes. Clinical criteria alone identified 39.1% (238/608) standard-risk episodes; 5.9% (14/238) had severe events. Prospectively using the SDR, the SHR group encompassed 76.6% (92/120) of episodes; severe events occurred in 20% (3/15) of standard-risk episodes included due to elevated procalcitonin ≥0.4 ng/mL. The SHR group had more blood stream infections [21.7% (20/92) vs. 0% (0/28); P = 0.007] and intensive care admissions [13% (12/92) vs. 3.6% (1/28); P = 0.158]. In conclusion, the SDR with serial procalcitonin aided in identifying severe events in clinical standard-risk episodes, but analysis was limited. Institutions may consider similar internal evaluation methodology before FN episode risk stratification.
Collapse
Affiliation(s)
- C. N. Nessle
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - T. Braun
- School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - S. W. Choi
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - R. Mody
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
10
|
Salvador C, Meryk A, Hetzer B, Bargehr C, Kropshofer G, Meister B, Anliker M, Crazzolara R. Immature platelet fraction predicts early marrow recovery after severe chemotherapy associated neutropenia. Sci Rep 2023; 13:3371. [PMID: 36849723 PMCID: PMC9971198 DOI: 10.1038/s41598-023-30469-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/23/2023] [Indexed: 03/01/2023] Open
Abstract
Febrile neutropenia secondary to chemotherapy is one of the most critical complications in cancer treatment. The aim of this study was to determine if an increase in the percentage of immature platelet fraction (IPF%) might predict early neutrophil recovery following cytostatic-dependent aplasia. A retrospective cohort study compared serial complete blood counts and the level of C-reactive protein (CRP) following induction chemotherapy for Ewing sarcoma and Non-Ewing sarcoma patients. The measurements were taken on a Sysmex XE-2100 instrument. A total of 287 paired samples from 28 children after the first cycle of chemotherapy were analyzed to test if an increase in the IPF% anticipated the CRP peak and recovery of neutrophil count. The chemotherapy associated nadir of neutrophils, reticulocytes and platelets was reached at 9.7 ± 1.5, 11.0 ± 1.7 and 11.9 ± 0.9 days (mean ± SD) respectively, in Ewing sarcoma patients. Still in severe neutropenia, IPF% was the first parameter that significantly increased and anticipated the CRP peak (11.9 ± 1.6 days, mean ± SD). The IPF% continuously increased (maximum = 6.56% ± 2.8%, mean ± SD) and peaked at 12.2 ± 1.4 days (mean ± SD) after commencement of chemotherapy. Compared to neutrophil recovery (14.6 ± 1.4 days, mean ± SD), the IPF% peak was anticipated by 2.4 days (p = 0.0085). Although variably treated, in non-Ewing sarcoma patients the effect was similar and the IPF% peak anticipated neutrophil recovery by 6.8 ± 4.7 days (p < 0.01). IPF% increased significantly at > 48 h before neutrophil recovery in patients treated with chemotherapy. IPF% is an inexpensive parameter and may be valuable in the management of febrile neutropenia.
Collapse
Affiliation(s)
- Christina Salvador
- grid.5361.10000 0000 8853 2677Division of Hematology and Oncology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Meryk
- grid.5361.10000 0000 8853 2677Division of Hematology and Oncology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Benjamin Hetzer
- grid.5361.10000 0000 8853 2677Division of Hematology and Oncology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Caroline Bargehr
- grid.5361.10000 0000 8853 2677Division of Hematology and Oncology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Gabriele Kropshofer
- grid.5361.10000 0000 8853 2677Division of Hematology and Oncology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Bernhard Meister
- grid.5361.10000 0000 8853 2677Division of Hematology and Oncology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Anliker
- grid.5361.10000 0000 8853 2677Central Institute for Medical and Chemical Laboratory Diagnosis, Medical University of Innsbruck, Innsbruck, Austria
| | - Roman Crazzolara
- Division of Hematology and Oncology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria.
| |
Collapse
|
11
|
Wattier RL, Esbenshade AJ. From "More is Better" to "Less is More": A Commentary on Antimicrobial Use in Pediatric Oncology. J Pediatric Infect Dis Soc 2022; 11:229-238. [PMID: 35099542 DOI: 10.1093/jpids/piab111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/09/2021] [Indexed: 11/14/2022]
Abstract
Reducing avoidable antimicrobial exposure to pediatric patients with cancer is achievable and necessary to promote optimal short- and long-term outcomes. Multiple evidence-based practices are already well established but should be more consistently implemented. Important opportunities exist to further improve the evidence to guide selective antimicrobial use in pediatric oncology.
Collapse
Affiliation(s)
- Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California San Francisco, San Francisco, California, USA
| | - Adam J Esbenshade
- Department of Pediatrics, Division of Hematology/Oncology, Vanderbilt University, Nashville, Tennessee, USA
| |
Collapse
|
12
|
Tong WH. Comment on: "Citrulline as a biomarker of bacteraemia during treatment for childhood acute lymphoblastic leukaemia". Pediatr Blood Cancer 2022; 69:e29409. [PMID: 34676976 DOI: 10.1002/pbc.29409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Wing H Tong
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center, Leiden, The Netherlands.,Argos Zorggroep "DrieMaasStede,", Center for Specialized Geriatric Care, Schiedam, The Netherlands
| |
Collapse
|
13
|
Morgan JE, Phillips B. PAnTher Cub: procalcitonin-guided antibiotic therapy for febrile neutropenia in children and young people with cancer - a single-arm pilot study. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2021-001339. [PMID: 36053620 PMCID: PMC8928328 DOI: 10.1136/bmjpo-2021-001339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/28/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Febrile neutropenia (FN) is a common complication of cancer treatment in children and young people, and many episodes are over-treated. Procalcitonin, may be an appropriate tool to guide the stopping of antibiotics in those at low risk of serious bacterial infection. Supportive care trials in this population have proven to be difficult to undertake. This single-arm pilot study aimed to evaluate whether a study using a procalcitonin-guided stopping-rule for antibiotics in paediatric FN is possible. METHODS Daily procalcitonin levels were performed during episodes of FN and clear guidance given for antibiotic discontinuation. Episode data and quantitative feasibility data were collected alongside interviews with professionals and ethnographic observations. Analysis was descriptive. RESULTS Of 32 patients and families approached, 28 patients consented, and 13 had febrile neutropenia. In total, 16 episodes were included in the study. All relevant FN episodes had data captured, with adequate data collection. There were no significant safety events. In 4/8 (50%) of episodes without clear microbiologically documented or clinical infection, antibiotics were reduced in duration or in spectrum. Interviews with professionals revealed the importance of the research, the value of key individuals in the study team, particular challenges of this protocol and suggestions for study improvements. CONCLUSIONS Studies to evaluate procalcitonin-guided approaches to stopping antibiotics in paediatric FN are possible.
Collapse
Affiliation(s)
- Jessica Elizabeth Morgan
- Department of Paediatric Haematology and Oncology, Leeds Children's Hospital, Leeds, UK .,Centre for Reviews and Dissemination, University of York, York, UK
| | - Bob Phillips
- Department of Paediatric Haematology and Oncology, Leeds Children's Hospital, Leeds, UK.,Centre for Reviews and Dissemination, University of York, York, UK
| |
Collapse
|
14
|
Bruns N, Dohna-Schwake C. Antibiotics in critically ill children-a narrative review on different aspects of a rational approach. Pediatr Res 2022; 91:440-446. [PMID: 34873285 PMCID: PMC8816725 DOI: 10.1038/s41390-021-01878-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 11/09/2021] [Accepted: 11/13/2021] [Indexed: 12/19/2022]
Abstract
Especially critically ill children are exposed to antibiotic overtreatment, mainly caused by the fear of missing out a severe bacterial infection. Potential adverse effects and selection of multi-drug resistant bacteria play minor roles in decision making. This narrative review first describes harm from antibiotics and second focuses on different aspects that could help to reduce antibiotic overtreatment without harming the patient: harm from antibiotic treatment, diagnostic approaches, role of biomarkers, timing of antibiotic therapy, empiric therapy, targeted therapy, and therapeutic drug monitoring. Wherever possible, we linked the described evidence to the current Surviving Sepsis Campaign guidelines. Antibiotic stewardship programs should help guiding antibiotic therapy for critically ill children. IMPACT: Critically ill children can be harmed by inadequate or overuse of antibiotics. Hemodynamically unstable children with a suspicion of infection should be immediately treated with broad-spectrum antibiotics. In contrast, in hemodynamically stable children with sepsis and organ dysfunction, a time frame of 3 h for proper diagnostics may be adequate before starting antibiotics if necessary. Less and more targeted antibiotic treatment can be achieved via antibiotic stewardship programs.
Collapse
Affiliation(s)
- Nora Bruns
- grid.5718.b0000 0001 2187 5445Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany. .,Westdeutsches Zentrum für Infektiologie, University of Duisburg-Essen, Essen, Germany.
| |
Collapse
|
15
|
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.
Collapse
|
16
|
Doerflinger M, Haeusler GM, Li-Wai-Suen CSN, Clark JE, Slavin M, Babl FE, Allaway Z, Mechinaud F, Smyth GK, De Abreu Lourenco R, Phillips B, Pellegrini M, Thursky KA. Procalcitonin and Interleukin-10 May Assist in Early Prediction of Bacteraemia in Children With Cancer and Febrile Neutropenia. Front Immunol 2021; 12:641879. [PMID: 34093531 PMCID: PMC8173204 DOI: 10.3389/fimmu.2021.641879] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/27/2021] [Indexed: 12/23/2022] Open
Abstract
Objectives Febrile neutropenia (FN) causes treatment disruption and unplanned hospitalization in children with cancer. Serum biomarkers are infrequently used to stratify these patients into high or low risk for serious infection. This study investigated plasma abundance of cytokines in children with FN and their ability to predict bacteraemia. Methods Thirty-three plasma cytokines, C-reactive protein (CRP) and procalcitonin (PCT) were measured using ELISA assays in samples taken at FN presentation (n = 79) and within 8–24 h (Day 2; n = 31). Optimal thresholds for prediction of bacteraemia were identified and the predictive ability of biomarkers in addition to routinely available clinical variables was assessed. Results The median age of included FN episodes was 6.0 years and eight (10%) had a bacteraemia. On presentation, elevated PCT, IL-10 and Mip1-beta were significantly associated with bacteraemia, while CRP, IL-6 and IL-8 were not. The combination of PCT (≥0.425 ng/ml) and IL-10 (≥4.37 pg/ml) had a sensitivity of 100% (95% CI 68.8–100%) and specificity of 89% (95% CI 80.0–95.0%) for prediction of bacteraemia, correctly identifying all eight bacteraemia episodes and classifying 16 FN episodes as high-risk. There was limited additive benefit of incorporating clinical variables to this model. On Day 2, there was an 11-fold increase in PCT in episodes with a bacteraemia which was significantly higher than that observed in the non-bacteraemia episodes. Conclusion Elevated PCT and IL-10 accurately identified all bacteraemia episodes in our FN cohort and may enhance the early risk stratification process in this population. Prospective validation and implementation is required to determine the impact on health service utilisation.
Collapse
Affiliation(s)
- Marcel Doerflinger
- Infectious Diseases and Immune Defence Division, Walter and Eliza Hall Institute for Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Infection and Immunity Theme, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, VIC, Australia
| | - Connie S N Li-Wai-Suen
- Infectious Diseases and Immune Defence Division, Walter and Eliza Hall Institute for Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia
| | - Julia E Clark
- Queensland Children's Hospital, Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
| | - Monica Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.,Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Franz E Babl
- Infection and Immunity Theme, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Emergency Department, Royal Children's Hospital, Parkville, VIC, Australia.,Paediatric Emergency Medicine Centre of Research Excellence, ED Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Zoe Allaway
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, VIC, Australia
| | - Francoise Mechinaud
- Unité D'hématologie Immunologie Pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, Paris, France
| | - Gordon K Smyth
- Infectious Diseases and Immune Defence Division, Walter and Eliza Hall Institute for Medical Research, Parkville, VIC, Australia.,School of Mathematics and Statistics, The University of Melbourne, Melbourne, VIC, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, NSW, Australia
| | - Bob Phillips
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, United Kingdom
| | - Marc Pellegrini
- Infectious Diseases and Immune Defence Division, Walter and Eliza Hall Institute for Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, VIC, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
17
|
Lehrnbecher T, Averbuch D, Castagnola E, Cesaro S, Ammann RA, Garcia-Vidal C, Kanerva J, Lanternier F, Mesini A, Mikulska M, Pana D, Ritz N, Slavin M, Styczynski J, Warris A, Groll AH. 8th European Conference on Infections in Leukaemia: 2020 guidelines for the use of antibiotics in paediatric patients with cancer or post-haematopoietic cell transplantation. Lancet Oncol 2021; 22:e270-e280. [PMID: 33811814 DOI: 10.1016/s1470-2045(20)30725-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 11/27/2022]
Abstract
Paediatric patients with cancer and those undergoing haematopoietic cell transplantation are at high risk of bacterial infections. The 8th European Conference on Infections in Leukaemia (ECIL-8) convened a Paediatric Group to review the literature and to formulate recommendations for the use of antibiotics according to the European Society of Clinical Microbiology and Infectious Diseases grading system. The evaluation of antibacterial prophylaxis included mortality, bloodstream infection, febrile neutropenia, emergence of resistance, and adverse effects as endpoints. Initial antibacterial therapy and antibiotic de-escalation or discontinuation focused on patients with a clinically stable condition and without previous infection or colonisation by resistant bacteria, and on patients with a clinically unstable condition or with previous infection or colonisation by resistant bacteria. The final considerations and recommendations of the ECIL-8 Paediatric Group on antibacterial prophylaxis, initial therapy, and de-escalation strategies are summarised in this Policy Review.
Collapse
Affiliation(s)
- Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt, Germany.
| | - Dina Averbuch
- Department of Pediatrics, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Roland A Ammann
- Pediatric Hematology and Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Carolina Garcia-Vidal
- Department of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain; IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jukka Kanerva
- Division of Hematology-Oncology and Stem Cell Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fanny Lanternier
- Infectious Diseases Unit, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris, Paris, France
| | - Alessio Mesini
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Dorothea Pana
- Department of Medicine, European University of Cyprus, Nicosia, Cyprus
| | - Nicole Ritz
- Pediatric Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Basel, Switzerland
| | - Monica Slavin
- Department of Infectious Diseases and National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation, Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | | |
Collapse
|
18
|
Anderson K, Bradford N, Edwards R, Nicholson J, Lockwood L, Clark JE. Improving management of fever in neutropenic children with cancer across multiple sites. Eur J Cancer Care (Engl) 2021; 30:e13413. [PMID: 33511731 DOI: 10.1111/ecc.13413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/28/2020] [Accepted: 01/06/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of a clinical pathway in achieving antibiotic administration in less than 60 minutes for children with cancer, presenting with fever and neutropenia. Secondary objectives were to determine association between time to antibiotics (TTA) and other variables including fever duration, location of care and intravenous access types. METHODS Following introduction of the clinical pathway, we collected prospective data about management of all cases that did and did not use the pathway across multiple sites over 16 months. A follow-up audit was conducted after 12 months. RESULTS We evaluated a total of 453 presentations. Use of the clinical pathway was significantly associated with achieving TTA in less than 60 minutes (RR 0.69, 95% CI 0.56-0.85, p = <0.001). Despite varying use of the pathway over time, the median time to antibiotics was achieved in both the initial study period (57 minutes) and sustained at follow-up (60 minutes). TTA was also associated with types of intravenous access device and location of care and with length of stay. We did not find any association between TTA and any other variables. CONCLUSION Clinical pathways improve fever management in this patient cohort. Ongoing education and auditing to identify factors which impact processes of care are necessary.
Collapse
Affiliation(s)
- Katrina Anderson
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Natalie Bradford
- Cancer and Palliative Care Outcomes Centre and Centre for Children's Health Research, Queensland University of Technology, South Brisbane, Qld, Australia
| | - Rachel Edwards
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Jessica Nicholson
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Liane Lockwood
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Julia E Clark
- Infection Management and Prevention Service, Queensland Children's Hospital, South Brisbane, Qld, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, Australia
| |
Collapse
|
19
|
De Pietri S, Frandsen TL, Christensen M, Grell K, Rathe M, Müller K. Citrulline as a biomarker of bacteraemia during induction treatment for childhood acute lymphoblastic leukaemia. Pediatr Blood Cancer 2021; 68:e28793. [PMID: 33155402 DOI: 10.1002/pbc.28793] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Systemic infections are a major cause of morbidity in children with acute lymphoblastic leukaemia (ALL). However, identification of patients at increased risk is still a challenge. Knowing that both neutropaenia and gastrointestinal toxicity are risk factors for bacteraemia, we aimed at comparing absolute neutrophil counts (ANC) and plasma citrulline levels (indicating enterocyte loss) in children with ALL with and without bacteraemia during induction treatment. PROCEDURE We prospectively included 61 children with ALL treated according to the Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL-2008 protocol. ANC and plasma C-reactive protein (CRP) were measured on treatment days 1, 8, 15, 22 and 29. Plasma citrulline was measured on days 1, 8, 15 and 29. Bacteraemia episodes during induction treatment were recorded retrospectively. RESULTS Nineteen of sixty-one (31%) patients experienced bacteraemia occurring on median day 13 (range 5-20). Patients with bacteraemia during induction treatment had lower citrulline level on day 15 (P < .01) compared to patients without bacteraemia, indicating more severe enterocyte loss. Nevertheless, ANC was similar in the two patient groups on days 8 and 15. CRP was negatively correlated with same-day citrulline (P < .03 for all) and ANC (P < .04 for all). CONCLUSIONS During chemotherapy-induced neutropaenia, plasma citrulline may help identify patients at increased risk of bacteraemia.
Collapse
Affiliation(s)
- Silvia De Pietri
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mette Christensen
- Department of Clinical Genetics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kathrine Grell
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Mathias Rathe
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Klaus Müller
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Institute for Inflammation Research, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
20
|
First Insights into Clinical and Resistance Features of Infections by Klebsiella pneumoniae among Oncological Patients from a Referral Center in Amazon Region, Brazil. Infect Dis Rep 2020; 12:110-120. [PMID: 33287355 PMCID: PMC7768515 DOI: 10.3390/idr12030021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 12/25/2022] Open
Abstract
Klebsiella pneumoniae appears as one of the most prevalent pathogens among cancer patients. The present study investigates the clinical, epidemiological and microbiological aspects related to infections caused by K. pneumoniae in cancer patients treated at an oncology referral center in the state of Pará, Amazon region, Brazil. Between July 2017 to July 2019, an epidemiological, observational, cross-sectional study, with a descriptive and analytical approach was conducted, including patients with confirmed diagnosis of cancer who acquired infection by K. pneumoniae 72 h after hospital admission. K. pneumoniae isolates included in the study were obtained from different clinical materials (blood, urine, catheter tip and bladder catheter, orotracheal secretions, oncological and surgical wounds). Antimicrobial susceptibility testing and molecular detection of the carbapenemase-encoding genes were performed. A high prevalence of MDR K. pneumoniae isolates was observed, including two colistin-resistant isolates and seven isolates harboring blaKPC-1 gene. To conclude, our findings provide the firsts insights into the epidemiology and infection by K. pneumoniae in the state of Pará, Brazil, and may be useful on treatment guidance and establishment of strategies to control the spread of resistance strains of K. pneumoniae in the region.
Collapse
|
21
|
Antibiotische Therapie bei kritisch kranken Kindern – Ist weniger mehr? Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-01027-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ZusammenfassungDie antibiotische Therapie stellt eine wichtige und in vielen Fällen unverzichtbare Maßnahme zum Erreichen einer Restitutio ad integrum bei bakteriellen Infektionen dar. Hierdurch können auch schwere Infektionen bei immungeschwächten Patienten geheilt werden. Wir wissen heute aber auch, dass insbesondere kritisch kranke Kinder häufig inadäquat antibiotisch behandelt werden – mit ebenfalls potenziell schädlichen Nebenwirkungen. In diesem Spannungsfeld aus kritisch krankem Kind, der Angst, etwas zu verpassen, und potenzieller Übertherapie ist es oft nicht einfach, eine rationale Therapieentscheidung zu fällen. Im vorliegenden Review werden aktuelle Studien zu wichtigen Aspekten der antibiotischen Therapie bei kritisch kranken Kindern beleuchtet und im Hinblick auf klinische Umsetzbarkeit interpretiert. Folgende Teilaspekte werden besprochen: 1) Zeitpunkt der antibiotischen Therapie und Möglichkeiten eines abwartenden Verhaltens, 2) die Auswahl der Antibiotika in der empirischen Therapie, 3) Deeskalationsstrategien und 4) die Dauer der antibiotischen Therapie. Antibiotic-Stewardship-Programme, unter Einbeziehung von pädiatrischen Infektiologen, klinischen Pharmazeuten und Mikrobiologen, spielen bei den häufig schwierigen klinischen Entscheidungen eine entscheidende Rolle.
Collapse
|
22
|
Siegmund M, Pagel J, Scholz T, Rupp J, Härtel C, Lauten M. Pro-inflammatory cytokine ratios determine the clinical course of febrile neutropenia in children receiving chemotherapy. Mol Cell Pediatr 2020; 7:5. [PMID: 32519027 PMCID: PMC7283414 DOI: 10.1186/s40348-020-00097-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/21/2020] [Indexed: 11/23/2022] Open
Abstract
Background Febrile neutropenia is a common and serious complication during treatment of childhood cancer. Empirical broad-spectrum antibiotics are usually administered until neutrophil cell count recovery. It was the aim of this study to investigate cytokine profiles as potential biomarkers using in-vitro sepsis models to differentiate between distinct clinical courses of febrile neutropenia (FN). Methods We conducted an observational study in FN episodes of pediatric oncology patients. Courses of neutropenia were defined as severe in case of proven blood stream infection or clinical evidence of complicated infection. We collected blood samples at various time points from the onset of FN and stimulated ex vivo with lipopolysaccharide (LPS) and Staphylococcus epidermidis (SE) for 24 h. Twenty-seven cytokine levels were measured in the whole blood culture supernatants by a multiplex immunoassay system. Results Forty-seven FN episodes from 33 children were investigated. IL-8, IL-1β, and MCP-1 expression increased significantly over time. IL-8, MIP-1α, MIP-1β, MCP-1, and TNF-α showed significantly lower concentration in patients with a clinically severe course of the FN. Conclusions Distinct patterns of cytokine profiles seem to be able to determine infectious FN and to predict the severity of its clinical course. If these data can be verified in a multi-centre setting, this may finally lead to an individualized treatment strategy facilitating antibiotic stewardship in these patients.
Collapse
Affiliation(s)
- Mira Siegmund
- Department of Pediatrics, Pediatric Hematology and Oncology, University of Lübeck, 23538, Lübeck, Germany
| | - Julia Pagel
- Department of Pediatrics, Pediatric Hematology and Oncology, University of Lübeck, 23538, Lübeck, Germany.,Department of Infectious Diseases and Microbiology, University of Lübeck, Lübeck, Germany.,German Center for Infection Research (DZIF), partner site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany
| | - Tasja Scholz
- Department of Pediatrics, Pediatric Hematology and Oncology, University of Lübeck, 23538, Lübeck, Germany
| | - Jan Rupp
- Department of Infectious Diseases and Microbiology, University of Lübeck, Lübeck, Germany.,German Center for Infection Research (DZIF), partner site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany
| | - Christoph Härtel
- Department of Pediatrics, Pediatric Hematology and Oncology, University of Lübeck, 23538, Lübeck, Germany
| | - Melchior Lauten
- Department of Pediatrics, Pediatric Hematology and Oncology, University of Lübeck, 23538, Lübeck, Germany.
| |
Collapse
|
23
|
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).
Collapse
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
| | | |
Collapse
|
24
|
Hinestroza-Palomino ML, Peralta-Ver MJ, Contreras-Ortiz JO, Garcés-Samudio C, Beltrán-Arroyave C. Comportamiento de un modelo de predicción de infección bacteriana invasiva en niños con cáncer, neutropenia y fiebre. INFECTIO 2020. [DOI: 10.22354/in.v24i2.835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objetivo: Describir el comportamiento de un modelo de predicción de infección bacteriana invasiva en niños con cáncer que cursan con neutropenia y fiebre,atendidos en el Hospital Infantil San Vicente Fundación (HISVF), en el año 2017. Materiales y métodos: Estudio descriptivo, de corte transversal y de período,que incluyó pacientes menores de 14 años con diagnóstico de algún tipo de cáncer que ingresaron al HISVF entre enero y diciembre de 2017, con diagnóstico de neutropenia y cuadro febril. Resultados: Se encontraron 99 episodios en 44 pacientes con NF. Al analizar la muestra según el grupo de riesgo estratificado y el desenlace aislamiento microbiológico o muerte, se encontraron diferencias entre los dos grupos. Estas diferencias muestran una mayor mortalidad y frecuencia de infección bacteriana invasiva en los pacientes clasificados como de alto riesgo.Discusión: La aplicación de estos criterios puede ser usada para un mejor direccionamiento del enfoque terapéutico incluyendo: el uso racional de antibióticos y un alta temprana o un seguimiento ambulatorio.
Collapse
|
25
|
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.
Collapse
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
| | | |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Vliora C, Papadakis V, Doganis D, Tourkantoni N, Paisiou A, Kottaridi C, Kourlamba G, Zaoutis T, Kosmidis H, Kattamis A, Polychronopoulou S, Goussetis E, Giannouli G, Syridou G, Priftis K, Papaevangelou V. A prospective study on the epidemiology and clinical significance of viral respiratory infections among pediatric oncology patients. Pediatr Hematol Oncol 2019; 36:173-186. [PMID: 31215284 DOI: 10.1080/08880018.2019.1613462] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Respiratory infections in oncology are both common and potentially severe. However, there is still a gap in the literature, regarding the epidemiology of viral respiratory infections in children with cancer. We prospectively enrolled 224 patients, from September 2012 to August 2015. The cohort included children with hematologic or solid malignancies receiving chemotherapy, or undergoing hemopoietic stem cell transplantation, outpatients/inpatients exhibiting signs/symptoms of febrile/afebrile upper/lower respiratory infection. Viral infection was diagnosed by detection of ≥1 viruses from a sample at time of enrollment, using the CLART® PneumoVir kit (GENOMICA, Spain). Α detailed questionnaire including demographics and medical history was also completed. Samples were processed in batches, results were communicated as soon as they became available. Children recruited in whom no virus was detected composed the no virus detected group. Viral prevalence was 38.4% in children presenting with respiratory illness. A single virus was found in 30.4%, with RSV being the most frequent. Viral coinfections were detected in 8%. Children with viral infection were more likely to be febrile upon enrollment and to present with lower respiratory signs/symptoms. They had longer duration of illness and they were more likely to receive antibiotics/antifungals. Only 22% of children with influenza received oseltamivir. Mortality was low (2.7%), however, pediatric intensive care unit (PICU) admission and death were correlated with virus detection. In our study mortality was low and PICU admission was related to virus identification. Further research is needed to clarify whether antibiotics in virus-proven infection are of value and underline the importance of oseltamivir's timely administration in influenza.
Collapse
Affiliation(s)
- Christianna Vliora
- a Third Department of Pediatrics , National and Kapodistrian University of Athens, "ATTIKON" University Hospital , Athens , Greece
| | - Vassilios Papadakis
- b Department of Pediatric Hematology-Oncology , Athens , Greece , "Aghia Sofia" Children's Hospital
| | - Dimitrios Doganis
- c Oncology Department , " P&A Kyriakou" Children's Hospital , Athens , Greece
| | - Natalia Tourkantoni
- d Hematology-Oncology Unit, First Department of Pediatrics , National and Kapodistrian University of Athens, "Aghia Sofia" Children's Hospital , Athens , Greece
| | - Anna Paisiou
- e Stem Cell Transplant Unit , Aghia Sofia Children's Hospital , Athens , Greece
| | | | - Georgia Kourlamba
- g The Stavros Niarchos Foundation-Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), First and Second Departments of Pediatrics, National and Kapodistrian University of Athens , Athens , Greece
| | - Theoklis Zaoutis
- g The Stavros Niarchos Foundation-Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), First and Second Departments of Pediatrics, National and Kapodistrian University of Athens , Athens , Greece
| | - Helen Kosmidis
- c Oncology Department , " P&A Kyriakou" Children's Hospital , Athens , Greece
| | - Antonis Kattamis
- d Hematology-Oncology Unit, First Department of Pediatrics , National and Kapodistrian University of Athens, "Aghia Sofia" Children's Hospital , Athens , Greece
| | - Sophia Polychronopoulou
- b Department of Pediatric Hematology-Oncology , Athens , Greece , "Aghia Sofia" Children's Hospital
| | - Evgenios Goussetis
- e Stem Cell Transplant Unit , Aghia Sofia Children's Hospital , Athens , Greece
| | - Georgia Giannouli
- a Third Department of Pediatrics , National and Kapodistrian University of Athens, "ATTIKON" University Hospital , Athens , Greece
| | - Garyfallia Syridou
- a Third Department of Pediatrics , National and Kapodistrian University of Athens, "ATTIKON" University Hospital , Athens , Greece
| | - Kostas Priftis
- a Third Department of Pediatrics , National and Kapodistrian University of Athens, "ATTIKON" University Hospital , Athens , Greece
| | - Vassiliki Papaevangelou
- a Third Department of Pediatrics , National and Kapodistrian University of Athens, "ATTIKON" University Hospital , Athens , Greece
| |
Collapse
|
28
|
Aljabari S, Balch A, Larsen GY, Fluchel M, Workman JK. Severe Sepsis-Associated Morbidity and Mortality among Critically Ill Children with Cancer. J Pediatr Intensive Care 2018; 8:122-129. [PMID: 31404226 DOI: 10.1055/s-0038-1676658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 11/05/2018] [Indexed: 01/20/2023] Open
Abstract
Severe sepsis (SS) in pediatric oncology patients is a leading cause of morbidity and mortality. We investigated the incidence of and risk factors for morbidity and mortality among children diagnosed with cancer from 2008 to 2012, and admitted with SS during the 3 years following cancer diagnosis. A total of 1,002 children with cancer were included, 8% of whom required pediatric intensive care unit (PICU) admission with SS. Death and/or multiple organ dysfunction syndrome occurred in 34 out of 99 PICU encounters (34%). Lactate level and history of stem-cell transplantation were significantly associated with the development of death and/or organ dysfunction ( p < 0.05).
Collapse
Affiliation(s)
- Salim Aljabari
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Alfred Balch
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Gitte Y Larsen
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Mark Fluchel
- Division of Pediatric Hematology and Oncology, Department of pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Jennifer K Workman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| |
Collapse
|
29
|
Anoshirvani AA, Zarinfar N, Rafiee M, Zamani Z. Effect of Combination Therapy of Ceftazidime/Amikacin and Monotherapy with Imipenem on the Treatment of Fever and Neutropenia in Patients with Cancers. Open Access Maced J Med Sci 2018; 6:1423-1430. [PMID: 30159069 PMCID: PMC6108819 DOI: 10.3889/oamjms.2018.310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 07/23/2018] [Accepted: 07/26/2018] [Indexed: 11/10/2022] Open
Abstract
AIM: This study aimed to compare the effect of Imipenem monotherapy and combination therapy with Ceftazidime/Amikacin in febrile episodes in neutropenic cancer patients. MATERIALS AND METHODS: In this double-blind randomised trial, 122 adult patients with cancer, neutropenia and fever who were treated by chemotherapy were gathered by simple sampling method and were divided randomly to two equal Imipenem (IP) and Ceftazidime/Amikacin (CA) groups. 500 mg of Imipenem was administered every 6 hours IP group and 2 g of Ceftazidimeplus 15 mg/kg/day in 2 equally divided doses of Amikacin was administered in the CA group. The treatment was continued for 72 hours in both groups. Data were analysed with SPSS19. RESULTS: There was a significant difference between the mean temperatures of three days in each group (P < 0.001). There was no significant difference between the two groups regarding microbial response to antibiotics. There was no significant difference between 19 patients of IP and 13 patients of CA groups regarding bacteriologically documented infection (P = 0.3). CONCLUSION: Unmodified therapy by Imipenem is as effective as combinational therapy by Ceftazidime/Amikacin in clinically and bacteriologically documented infection.
Collapse
Affiliation(s)
- Ali Arash Anoshirvani
- Department of Hematology and Medical Oncology, Arak University of Medical Sciences, Arak, Iran
| | - Nader Zarinfar
- Department of Infectious Disease, Arak University of Medical Sciences, Arak, Iran
| | - Mohammad Rafiee
- Department of Statistics and Epidemiology, Arak University of Medical Sciences, Arak, Iran
| | - Zahra Zamani
- Department of Internal Medicine, Arak University of Medical Sciences, Arak, Iran
| |
Collapse
|
30
|
Initial Management of Fever and Neutropenia: A Practical Approach. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
31
|
Predictive value of PCT and IL-6 for bacterial infection in children with cancer and febrile neutropenia. Support Care Cancer 2018; 26:3819-3826. [PMID: 29777383 PMCID: PMC6182367 DOI: 10.1007/s00520-018-4249-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 05/06/2018] [Indexed: 12/17/2022]
Abstract
Purpose Only a third of children with cancer and febrile neutropenia (FN) have a proven bacterial infection; nevertheless, most children are hospitalized and treated with intravenous antibiotics. Several biomarkers have been proposed as predictive markers for bacterial infection in this population. We aimed to evaluate the role of interleukin-6 (IL-6) and procalcitonin (PCT) in diagnosing bacterial infection in children with cancer and FN. Methods The study population was derived from a prospective database (2006–2013, IL-8 study) comprising children with cancer who presented with FN. From stored plasma samples (taken at admission and/or at 12–24 h), we determined the PCT and IL-6 levels. Consequently, we explored their relation with the presence of bacterial infection (positive blood culture, radiologically documented infection or clinical bacterial focus). We predefined cutoff values at 60 ng/L for IL-6 and 0.25 ng/mL for PCT. Results Seventy-seven FN episodes in 55 children with cancer were included. In 18 episodes (23.4%), a bacterial infection was documented. Both at presentation and after 12–24 h, median values of IL-6 and PCT were significantly higher in patients with a bacterial infection compared to patients without a bacterial infection. With both biomarkers above cutoff values, sensitivity was 93% (with either one, this was even 100%). The identified group at low risk for bacterial infection comprised 41% of the population. Conclusion PCT and IL-6 are promising markers in identifying bacterial infection in children with cancer and FN. In a subsequent project, we will incorporate these biomarkers in a risk assessment model that we will test prospectively in a clinical trial.
Collapse
|
32
|
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.
Collapse
|
33
|
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.
Collapse
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
| |
Collapse
|
34
|
Cytokine Kinetics in Febrile Neutropenic Children: Insights on the Usefulness as Sepsis Biomarkers, Influence of Filgrastim, and Behavior of the IL-23/IL-17 Pathway. Mediators Inflamm 2017; 2017:8291316. [PMID: 28769538 PMCID: PMC5523193 DOI: 10.1155/2017/8291316] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/04/2017] [Accepted: 06/05/2017] [Indexed: 01/21/2023] Open
Abstract
Background The study aimed to describe the kinetics of various cytokines from day 1 to day 14 of the onset of fever in neutropenic children and to evaluate their performances as discriminators of sepsis in the first 24 hours of fever, the possible influence of filgrastim, and the functioning of the IL-23/IL-17 axis. Methods IL-1β, TNF-α, IL-10, IL-12/23p40, IL-21, IL-6, IL-8, IL-17, G-CSF, and GM-CSF were measured in plasma on days 1, 2, 3, 5, and 14 from the onset of fever in 35 patients. Results Thirteen patients (37.1%) developed sepsis. In mixed models, IL-6, IL-8, IL-10, and G-CSF showed higher estimated means in septic patients (P < 0.005), and IL-12/23p40 and IL-17 in nonseptic patients (P < 0.05). On day 1, IL-6, IL-8, and IL-10 appeared upregulated in patients who received filgrastim. Only IL-6, IL-8, IL-10, and procalcitonin were useful as discriminators of sepsis. Associating the markers with each other or to a risk assessment model improved performance. Conclusions Cytokines kinetics showed proinflammatory and anti-inflammatory responses similar to what is described in nonneutropenic patients. IL-8, IL-6, IL-10, and procalcitonin are useful as early biomarkers of sepsis. Filgrastim upregulates expression of these markers, and we observed deficiency in the IL-23-IL-17 axis accompanying sepsis.
Collapse
|
35
|
Abstract
Bacterial pneumonias exact unacceptable morbidity on patients with cancer. Although the risk is often most pronounced among patients with treatment-induced cytopenias, the numerous contributors to life-threatening pneumonias in cancer populations range from derangements of lung architecture and swallow function to complex immune defects associated with cytotoxic therapies and graft-versus-host disease. These structural and immunologic abnormalities often make the diagnosis of pneumonia challenging in patients with cancer and impact the composition and duration of therapy. This article addresses host factors that contribute to pneumonia susceptibility, summarizes diagnostic recommendations, and reviews current guidelines for management of bacterial pneumonia in patients with cancer.
Collapse
Affiliation(s)
- Justin L Wong
- Division of Internal Medicine, Department of Pulmonary, Critical Care and Sleep Medicine, The University of Texas Health Sciences Center, 6431 Fannin Street, MSB 1.434, Houston, TX 77030, USA
| | - Scott E Evans
- Division of Internal Medicine, Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1100, Houston, TX 77030, USA.
| |
Collapse
|
36
|
Lehrnbecher T, Robinson P, Fisher B, Alexander S, Ammann RA, Beauchemin M, Carlesse F, Groll AH, Haeusler GM, Santolaya M, Steinbach WJ, Castagnola E, Davis BL, Dupuis LL, Gaur AH, Tissing WJE, Zaoutis T, Phillips R, Sung L. Guideline for the Management of Fever and Neutropenia in Children With Cancer and Hematopoietic Stem-Cell Transplantation Recipients: 2017 Update. J Clin Oncol 2017; 35:2082-2094. [PMID: 28459614 DOI: 10.1200/jco.2016.71.7017] [Citation(s) in RCA: 277] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Purpose To update a clinical practice guideline (CPG) for the empirical management of fever and neutropenia (FN) in children with cancer and hematopoietic stem-cell transplantation recipients. Methods The International Pediatric Fever and Neutropenia Guideline Panel is a multidisciplinary and multinational group of experts in pediatric oncology and infectious diseases that includes a patient advocate. For questions of risk stratification and evaluation, we updated systematic reviews of observational studies. For questions of therapy, we conducted a systematic review of randomized trials of any intervention applied for the empirical management of pediatric FN. The Grading of Recommendation Assessment, Development and Evaluation approach was used to make strong or weak recommendations and to classify levels of evidence as high, moderate, low, or very low. Results Recommendations related to initial presentation, ongoing management, and empirical antifungal therapy of pediatric FN were reviewed; the most substantial changes were related to empirical antifungal therapy. Key differences from our 2012 FN CPG included the listing of a fourth-generation cephalosporin for empirical therapy in high-risk FN, refinement of risk stratification to define patients with high-risk invasive fungal disease (IFD), changes in recommended biomarkers and radiologic investigations for the evaluation of IFD in prolonged FN, and a weak recommendation to withhold empirical antifungal therapy in IFD low-risk patients with prolonged FN. Conclusion Changes to the updated FN CPG recommendations will likely influence the care of pediatric patients with cancer and those undergoing hematopoietic stem-cell transplantation. Future work should focus on closing research gaps and on identifying ways to facilitate implementation and adaptation.
Collapse
Affiliation(s)
- Thomas Lehrnbecher
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Paula Robinson
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Brian Fisher
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Sarah Alexander
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Roland A Ammann
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Melissa Beauchemin
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Fabianne Carlesse
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Andreas H Groll
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Gabrielle M Haeusler
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Maria Santolaya
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - William J Steinbach
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Elio Castagnola
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Bonnie L Davis
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - L Lee Dupuis
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Aditya H Gaur
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Wim J E Tissing
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Theo Zaoutis
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Robert Phillips
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| | - Lillian Sung
- Thomas Lehrnbecher, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt; Andreas H. Groll, University Children's Hospital, Muenster, Germany; Paula Robinson, Pediatric Oncology Group of Ontario; Sarah Alexander, L. Lee Dupuis, and Lillian Sung, The Hospital for Sick Children, Toronto, Ontario, Canada; Brian Fisher and Theo Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; Roland A. Ammann, Bern University Hospital, University of Bern, Switzerland; Melissa Beauchemin, Columbia University/Herbert Irving Cancer Center, New York, NY; Fabianne Carlesse, Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil; Gabrielle M. Haeusler, Peter MacCallum Cancer Centre, Melbourne; Monash Children's Hospital, Clayton, Victoria, Australia; Maria Santolaya, Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; William J. Steinbach, Duke University Medical Center, Durham, NC; Elio Castagnola, Istituto Giannina Gaslini, Genova, Italy; Bonnie L. Davis, High Tor Limited, Nassau, Bahamas; Aditya H. Gaur, St Jude Children's Research Hospital, Memphis, TN; Wim J.E. Tissing, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and Robert Phillips, Leeds Teaching Hospital, NHS Trust, Leeds; University of York, York, United Kingdom
| |
Collapse
|
37
|
Santolaya ME, Alvarez AM, Acuña M, Avilés CL, Salgado C, Tordecilla J, Varas M, Venegas M, Villarroel M, Zubieta M, Toso A, Bataszew A, Farfán MJ, de la Maza V, Vergara A, Valenzuela R, Torres JP. Efficacy and safety of withholding antimicrobial treatment in children with cancer, fever and neutropenia, with a demonstrated viral respiratory infection: a randomized clinical trial. Clin Microbiol Infect 2017; 23:173-178. [PMID: 27856269 PMCID: PMC7129180 DOI: 10.1016/j.cmi.2016.11.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 11/03/2016] [Accepted: 11/04/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine efficacy and safety of withholding antimicrobials in children with cancer, fever and neutropenia (FN) with a demonstrated respiratory viral infection. METHODS Prospective, multicentre, randomized study in children presenting with FN at five hospitals in Santiago, Chile, evaluated at admission for diagnosis of bacterial and viral pathogens including PCR-microarray for 17 respiratory viruses. Children positive for a respiratory virus, negative for a bacterial pathogen and with a favourable evolution after 48 h of antimicrobial therapy were randomized to either maintain or withhold antimicrobials. Primary endpoint was percentage of episodes with uneventful resolution. Secondary endpoints were days of fever/hospitalization, bacterial infection, sepsis, admission to paediatric intensive care unit (PICU) and death. RESULTS A total of 319 of 951 children with FN episodes recruited between July 2012 and December 2015 had a respiratory virus as a unique identified microorganism, of which 176 were randomized, 92 to maintain antimicrobials and 84 to withdraw. Median duration of antimicrobial use was 7 days (range 7-9 days) versus 3 days (range 3-4 days), with similar frequency of uneventful resolution (89/92 (97%) and 80/84 (95%), respectively, not significant; OR 1.48; 95% CI 0.32-6.83, p 0.61), and similar number of days of fever (2 versus 1), days of hospitalization (6 versus 6) and bacterial infections throughout the episode (2%-1%), with one case of sepsis requiring admission to PICU in the group that maintained antimicrobials, without any deaths. CONCLUSIONS The reduction of antimicrobials in children with FN and respiratory viral infections, based on clinical and microbiological/molecular diagnostic criteria, should favour the adoption of evidence-based management strategies in this population.
Collapse
Affiliation(s)
- M E Santolaya
- Department of Paediatrics, Hospital Dr Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs Network, Santiago, Chile
| | - A M Alvarez
- Department of Paediatrics, Hospital San Juan de Dios, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs Network, Santiago, Chile
| | - M Acuña
- Department of Paediatrics, Hospital Dr Roberto del Río, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs Network, Santiago, Chile
| | - C L Avilés
- Department of Paediatrics, Hospital San Borja Arriarán, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs Network, Santiago, Chile
| | - C Salgado
- Department of Paediatrics, Hospital Dr Exequiel González Cortés, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs Network, Santiago, Chile
| | - J Tordecilla
- Department of Paediatrics, Hospital Dr Roberto del Río, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs Network, Santiago, Chile
| | - M Varas
- Department of Paediatrics, Hospital San Juan de Dios, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs Network, Santiago, Chile
| | - M Venegas
- Department of Paediatrics, Hospital San Juan de Dios, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - M Villarroel
- Department of Paediatrics, Hospital Dr Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs Network, Santiago, Chile
| | - M Zubieta
- Department of Paediatrics, Hospital Dr Exequiel González Cortés, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs Network, Santiago, Chile
| | - A Toso
- Department of Paediatrics, Hospital Dr Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - A Bataszew
- Department of Paediatrics, Hospital Dr Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - M J Farfán
- Department of Paediatrics, Hospital Dr Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - V de la Maza
- Department of Paediatrics, Hospital Dr Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - A Vergara
- Centre for Molecular Studies, Hospital Dr Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - R Valenzuela
- Department of Paediatrics, Hospital Dr Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - J P Torres
- Department of Paediatrics, Hospital Dr Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile.
| |
Collapse
|
38
|
Delebarre M, Tiphaine A, Martinot A, Dubos F. Risk-stratification management of febrile neutropenia in pediatric hematology-oncology patients: Results of a French nationwide survey. Pediatr Blood Cancer 2016; 63:2167-2172. [PMID: 27569451 DOI: 10.1002/pbc.26121] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/31/2016] [Accepted: 06/06/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND In 2012, new international guidelines for children with chemotherapy-induced febrile neutropenia (FN) were issued, recommending reduced-intensity management strategy based on stratification of infectious risks. Some studies have highlighted practice disparities in different countries and within the same country. Our aim was to assess the current management strategies for the treatment of chemotherapy-induced FN in children in France. PROCEDURE This survey of all French pediatric oncology-hematology reference centers (n = 30) in late 2012 and early 2013 sent a standardized questionnaire to each center inquiring about their definition of an FN episode, its initial empiric treatment and ongoing management, use of management stratified by risk, and any criteria used for the risk assessment. Each center's management protocol was also analyzed. RESULTS All French reference centers participated in this survey, completing 88% of the questionnaire items. Definitions of both fever and neutropenia varied between centers. Ten centers used a risk-stratification strategy for initial management. In all, 42 probabilistic first-line antibiotic treatments were identified. After 48 hr of apyrexia, 17 units applied different forms of step-down therapy. CONCLUSIONS Most French centers already offered some form of reduced-intensity or step-down therapy, although they differed substantially in their management of FN episodes. Risk stratification with validated tools is essential to facilitate the implementation of the international recommendations, which would ultimately help to standardize practices in France.
Collapse
Affiliation(s)
- Mathilde Delebarre
- Univ. Lille, CHU Lille, Pediatric Emergency Unit & Infectious Diseases, Lille, France. .,Univ. Lille, EA2694, Public Health, Epidemiology and Quality of Care, Lille, France.
| | - Aude Tiphaine
- Univ. Lille, CHU Lille, Pediatric Emergency Unit & Infectious Diseases, Lille, France.,CHU Bordeaux, Pediatric Hematology-Oncology Unit, Bordeaux, France
| | - Alain Martinot
- Univ. Lille, CHU Lille, Pediatric Emergency Unit & Infectious Diseases, Lille, France.,Univ. Lille, EA2694, Public Health, Epidemiology and Quality of Care, Lille, France
| | - François Dubos
- Univ. Lille, CHU Lille, Pediatric Emergency Unit & Infectious Diseases, Lille, France.,Univ. Lille, EA2694, Public Health, Epidemiology and Quality of Care, Lille, France
| |
Collapse
|
39
|
Suh KH, Park SY, Kim SY, Lee JM. Urinary tract infections in pediatric oncology patients with febrile neutropenia. Yeungnam Univ J Med 2016. [DOI: 10.12701/yujm.2016.33.2.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Kyoo Hyun Suh
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
| | - Sun Young Park
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
| | - Sae Yoon Kim
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jae Min Lee
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
| |
Collapse
|