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Smith WT, Read J, Agarwal S, Tian G, Anum SJ, Choe M, Kurtz K, Tlais D, Shen X, Sarro J, Looney T, Porea T, Sauer H, Brackett J, Okcu MF, Chintagumpala M. Improving Time to Antibiotic Administration for Pediatric Oncology Patients With New-Onset Fever. JCO Oncol Pract 2024; 20:725-731. [PMID: 38354362 DOI: 10.1200/op.23.00314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 12/07/2023] [Accepted: 01/05/2024] [Indexed: 02/16/2024] Open
Abstract
PURPOSE Time to antibiotic administration (TTA) in <60 minutes for children with neutropenic fever presenting to an emergency room is associated with reduced incidence of sepsis and intensive care admission. As such, TTA is used as a national quality metric for pediatric oncology patients. At our center, in 2020, 19% of the hospitalized patients with a new fever encounter were receiving antibiotics in <60 minutes, prompting a multidisciplinary approach to reach a goal of >90% in all pediatric patients with cancer with a new fever. METHODS A multidisciplinary team completed four Plan-Do-Study-Act cycles between March 2021 and September 2023. We implemented education initiatives, an updated handoff smartphrase guiding the on-call team, an antibiotic champion (AC) nursing role, a revised fever plan for handoff, a rapid-response team to address new fevers, and an algorithm for blood culture collection. Data were collected, analyzed, and reported biweekly with feedback sought for delays in TTA. RESULTS There was a total of 639 new fevers in 329 unique oncology patients. As of September 4, 2023, average TTA decreased from 89 minutes at baseline to 46.4 minutes for more than 12 months. The percentage of patients receiving first dose of antibiotic in <60 minutes also increased from 19% to 93.7%, which was sustained as well. The most effective interventions were creation of the AC role and streamlining the blood culture collection process. CONCLUSION This project demonstrates the importance of multidisciplinary involvement for providing optimal care. Specific implementation of targeted education, an AC role, and development of an algorithm streamlining the processes led to meaningful targeted improvements. Further analyses will explore the impact of these interventions on patient outcomes.
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Affiliation(s)
- Wesley T Smith
- Department of Pediatrics, Division of Hematology/Oncology, University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Jay Read
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Shreya Agarwal
- Department of Pediatrics, Division of Hematology, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Gengwen Tian
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Shaniqua J Anum
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Michelle Choe
- Clinical Research Division, Department of Pediatrics, Fred Hutchinson Cancer Center, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Kristen Kurtz
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Dana Tlais
- Department of Oncology, Division of Neuro-Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Xiaofan Shen
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jill Sarro
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Thomas Looney
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy Porea
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Hannah Sauer
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Julienne Brackett
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - M Fatih Okcu
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Murali Chintagumpala
- Department of Pediatrics, Texas Children's Hematology and Oncology Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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Pulcini CD, Lentz S, Saladino RA, Bounds R, Herrington R, Michaels MG, Maurer SH. Emergency management of fever and neutropenia in children with cancer: A review. Am J Emerg Med 2021; 50:693-698. [PMID: 34879488 DOI: 10.1016/j.ajem.2021.09.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Care of pediatric cancer patients is increasingly being provided by physicians in community settings, including general emergency departments. Guidelines based on current evidence have standardized the care of children undergoing chemotherapy or hematopoietic stem cell transplantation (HSCT) presenting with fever and neutropenia (FN). OBJECTIVE This narrative review evaluates the management of pediatric patients with cancer and neutropenic fever and provides comparison with the care of the adult with neutropenic fever in the emergency department. DISCUSSION When children with cancer and FN first present for care, stratification of risk is based on a thorough history and physical examination, baseline laboratory and radiologic studies and the clinical condition of the patient, much like that for the adult patient. Prompt evaluation and initiation of intravenous broad-spectrum antibiotics after cultures are drawn but before other studies are resulted is critically important and may represent a practice difference for some emergency physicians when compared with standardized adult care. Unlike adults, all high-risk and most low-risk children with FN undergoing chemotherapy require admission for parenteral antibiotics and monitoring. Oral antibiotic therapy with close, structured outpatient monitoring may be considered only for certain low-risk patients at pediatric centers equipped to pursue this treatment strategy. CONCLUSIONS Although there are many similarities between the emergency approach to FN in children and adults with cancer, there are differences that every emergency physician should know. This review provides strategies to optimize the care of FN in children with cancer in all emergency practice settings.
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Affiliation(s)
- Christian D Pulcini
- Division of Emergency Medicine, Department of Surgery and Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Skyler Lentz
- Division of Emergency Medicine and Critical Care, Department of Surgery and Medicine, University of Vermont Larner College of Medicine, Burlington, VT, United States of America
| | - Richard A Saladino
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Richard Bounds
- Division of Emergency Medicine, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Ramsey Herrington
- Division of Emergency Medicine, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Marian G Michaels
- Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Scott H Maurer
- Division of Hematology/Oncology, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
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Abstract
PURPOSE Although cancer is uncommon, it is a significant cause of pediatric morbidity and mortality in the developing world. The need for intensive care in pediatric oncology has increased with more intense chemotherapeutic interventions. It is important to identify patients who will benefit from management in the intensive care unit (ICU), given the resource limitation in developing countries. In this review, we examine our institutional experience with pediatric patients with cancer needing ICU care. METHODS A retrospective chart review from December 2015 to June 2017 was performed with institutional review board approval for all pediatric oncology patients admitted to the ICU. Data collection included age, diagnosis, disease stage, Pediatric Risk of Mortality (PRISM III) score, and therapeutic interventions. RESULTS We reviewed 59 pediatric oncology ICU medical records. There were 36 boys (61%) and 23 girls (39%). The median age was 4 years. Average stay in the ICU was 4.6 days. Three significant reasons for ICU referral were respiratory distress, sepsis, and circulatory collapse. There were 34 ICU survivors (57.6%). Among those who survived the ICU, 20 patients (58.8%) later died of therapy-related complications. Factors related to increased ICU mortality included the need for mechanical ventilation, the need for inotropic support, the number of failing organs, and a high PRISM III score. CONCLUSION The mortality rate for pediatric oncology patients admitted to the ICU in developing countries is higher than in developed countries. Mortality was significantly related to the need for mechanical ventilation. PRISM III scoring can help identify patients who can benefit from ICU treatment, which is expensive in resource-limited low- and middle-income countries such as Pakistan.
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Affiliation(s)
| | - Saadiya Javed Khan
- Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
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Koenig C, Schneider C, Morgan JE, Ammann RA, Sung L, Phillips B. Interventions aiming to reduce time to antibiotics (TTA) in patients with fever and neutropenia during chemotherapy for cancer (FN), a systematic review. Support Care Cancer 2019; 28:2369-2380. [PMID: 31486984 PMCID: PMC7083808 DOI: 10.1007/s00520-019-05056-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/22/2019] [Indexed: 11/18/2022]
Abstract
Purpose Multiple interventions have been developed aiming to reduce time to antibiotics (TTA) in patients with fever and neutropenia (FN) following chemotherapy for cancer. We evaluated their effect to reduce TTA and their impact on important clinical outcomes in a systematic review. Methods The search covered seven databases. Biases and quality of studies were assessed with the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. Interventions could be implemented in any setting and performed by any person included in the FN management. Absolute change of TTA was the primary outcome. Registration: PROSPERO (CRD42018092948). Results Six thousand two hundred ninety-six titles and abstracts were screened, 177 studies were retrieved and 30 studies were included. Risk of bias was moderate to serious in 28 studies and low in two studies. All but one study reported a reduction of TTA after the intervention. Various types of interventions were implemented; they most commonly aimed at professionals. Most of the studies made more than one single intervention. Conclusion This review may help centers to identify their specific sources of delay and barriers to change and to define what intervention may be the best to apply. This review supports the assertion that TTA can be considered a measure of quality of care, emphasizes the importance of education and training, and describes the very different interventions which have effectively reduced TTA. Electronic supplementary material The online version of this article (10.1007/s00520-019-05056-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010, Bern, Switzerland. .,Centre for Reviews and Dissemination, University of York, York, UK.
| | - Christine Schneider
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010, Bern, Switzerland
| | - Jessica E Morgan
- Centre for Reviews and Dissemination, University of York, York, UK.,Leeds Children's Hospital, Leeds, UK
| | - Roland A Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010, Bern, Switzerland
| | - Lillian Sung
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, UK.,Leeds Children's Hospital, Leeds, UK
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Koenig C, Schneider C, Morgan JE, Ammann RA, Sung L, Phillips B. Association of time to antibiotics and clinical outcomes in patients with fever and neutropenia during chemotherapy for cancer: a systematic review. Support Care Cancer 2019; 28:1369-1383. [DOI: 10.1007/s00520-019-04961-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 06/19/2019] [Indexed: 02/07/2023]
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De Conno F, Ripamonti C, Sbanotto A, Ventafridda V. Oral Complications in Patients with Advanced Cancer. J Palliat Care 2019. [DOI: 10.1177/082585978900500102] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Disturbances caused by lesions of the oral cavity play an important part in the alteration of the qualtity of life of cancer patients. The main complications affecting the oral cavity are infections (fungal, viral, bacterial), neutropenic ulcers, drug-induced stomatitis, dry mouth, and taste alteration. Most of the information available about these entities has been acquired in the cancer patient without advanced disease. The little known about the epidemiology and physiopathology of such lesions in the advanced phase of cancer is presented and approaches to management are suggested.
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Affiliation(s)
- Franco De Conno
- Pain Therapy and Palliative Care Division, National Cancer Institute, Milan, Italy
| | - Carla Ripamonti
- Pain Therapy and Palliative Care Division, National Cancer Institute, Milan, Italy
| | - Alberto Sbanotto
- Pain Therapy and Palliative Care Division, National Cancer Institute, Milan, Italy
| | - Vittorio Ventafridda
- Pain Therapy and Palliative Care Division, National Cancer Institute, Milan, Italy
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Koenig C, Morgan J, Ammann RA, Sung L, Phillips B. Protocol for a systematic review of time to antibiotics (TTA) in patients with fever and neutropenia during chemotherapy for cancer (FN) and interventions aiming to reduce TTA. Syst Rev 2019; 8:82. [PMID: 30944024 PMCID: PMC6446276 DOI: 10.1186/s13643-019-1006-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 03/25/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Fever and neutropenia (FN) is a common complication of chemotherapy for cancer. Prompt empiric broad-spectrum antibiotic therapy in FN is typically considered standard of care, but the definition of prompt is not clear. We seek to systematically review the available data on the association between time to antibiotics (TTA) administration and clinical outcomes in patients with FN being treated with chemotherapy. There have been several efforts to reduce TTA in patients with FN, by implementing specific interventions, presuming there will be a beneficial effect on patient-important outcomes. This systematic review will also collect data on such interventions and their effect to reduce TTA and potentially change clinical outcomes. METHODS/DESIGN The search will cover MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, CINAHL, CDSR, CENTRAL, and LILACS. A full-search strategy is provided. Lists of studies identified by references cited and forward citation searching of included articles will also be reviewed. Studies will be screened, and data extracted by one researcher and independently checked by a second. Confounding biases and quality of studies will be assessed with the risk of bias in non-randomised studies-of interventions (ROBINS-I) tool. Data will be presented in narrative and tabular forms; in addition, if appropriate data is available, random effects meta-analysis will be used to examine TTA. A detailed analysis plan, including an assessment of heterogeneity and publication bias, is provided. DISCUSSION This study aims to evaluate the association between TTA and patient-important clinical outcomes. Additionally, it will identify, critically appraise, and synthesise information on performed interventions and its effect to reduce TTA as a way of gaining insight into the potential use of these approaches. This will provide better knowledge for an adjusted treatment approach of FN. SYSTEMATIC REVIEW REGISTRATION PROSPERO [ CRD42018092948 ].
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Affiliation(s)
- Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Jess Morgan
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Roland A. Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lillian Sung
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, UK
- Leeds Children’s Hospital, Leeds, UK
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8
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Carlesse F, Cappellano P, Quiles MG, Menezes LC, Petrilli AS, Pignatari AC. Clinical relevance of molecular identification of microorganisms and detection of antimicrobial resistance genes in bloodstream infections of paediatric cancer patients. BMC Infect Dis 2016; 16:462. [PMID: 27585633 PMCID: PMC5007997 DOI: 10.1186/s12879-016-1792-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 08/21/2016] [Indexed: 12/25/2022] Open
Abstract
Background Bloodstream infections (BSIs) are the major cause of mortality in cancer patients. Molecular techniques are used for rapid diagnosis of BSI, allowing early therapy and improving survival. We aimed to establish whether real-time quantitative polymerase chain reaction (qPCR) could improve early diagnosis and therapy in paediatric cancer patients, and describe the predominant pathogens of BSI and their antimicrobial susceptibility. Methods Blood samples were processed by the BACTEC system and microbial identification and susceptibility tests were performed by the Phoenix system. All samples were screened by multiplex 16 s rDNA qPCR. Seventeen species were evaluated using sex-specific TaqMan probes and resistance genes blaSHV, blaTEM, blaCTX, blaKPC, blaIMP, blaSPM, blaVIM, vanA, vanB and mecA were screened by SYBR Green reactions. Therapeutic efficacy was evaluated at the time of positive blood culture and at final phenotypic identification and antimicrobial susceptibility results. Results We analyzed 69 episodes of BSI from 64 patients. Gram-positive bacteria were identified in 61 % of the samples, Gram-negative bacteria in 32 % and fungi in 7 %. There was 78.2 % of agreement between the phenotypic and molecular methods in final species identification. The mecA gene was detected in 81.4 % of Staphylococcus spp., and 91.6 % were concordant with the phenotypic method. Detection of vanA gene was 100 % concordant. The concordance for Gram-negative susceptibilities was 71.4 % for Enterobacteriaceae and 50 % for Pseudomonas aeruginosa. Therapy was more frequently inadequate in patients who died, and the molecular test was concordant with the phenotypic susceptibility test in 50 %. Conclusions qPCR has potential indication for early identification of pathogens and antimicrobial resistance genes from BSI in paediatric cancer patients and may improve antimicrobial therapy.
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Affiliation(s)
- Fabianne Carlesse
- Institute of Paediatric Oncology, Universidade Federal de São Paulo, Rua Botucatu 743, São Paulo, 04037020, Brazil.
| | - Paola Cappellano
- Infectious Diseases Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | - Antonio Sérgio Petrilli
- Institute of Paediatric Oncology, Universidade Federal de São Paulo, Rua Botucatu 743, São Paulo, 04037020, Brazil
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Adamson PC. Improving the outcome for children with cancer: Development of targeted new agents. CA Cancer J Clin 2015; 65:212-20. [PMID: 25754421 PMCID: PMC4629487 DOI: 10.3322/caac.21273] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 02/09/2015] [Accepted: 02/09/2015] [Indexed: 01/27/2023] Open
Abstract
The outcome for children with cancer has improved significantly over the past 60 years, with greater than 80% of patients today becoming 5-year survivors. Despite this progress, cancer remains the leading cause of death from disease in children in the United States, and significant short-term and long-term treatment toxicities continue to impact the majority of children with cancer. The development of targeted new agents offers the prospect of potentially more effective and less toxic treatment for children. More than a decade since imatinib mesylate was introduced into the treatment of children with Philadelphia chromosome-positive acute lymphoblastic leukemia, transforming its outcome, a range of targeted agents has undergone study in pediatric cancer patients. Early lessons learned from these studies include a better understanding of the adverse event profile of these drugs in children, the challenge of developing pediatric-specific formulations, and the continued reliance on successful development for adult cancer indications on pediatric drug development. The collaborative research infrastructure for children with cancer in the United States is well positioned to advance novel treatments into clinical investigations for a spectrum of rare and ultra-rare childhood cancers. A greater investment of resources in target discovery and validation can help drive much needed development of new, more effective treatments for children with cancer.
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Affiliation(s)
- Peter C. Adamson
- Corresponding author: Peter C. Adamson, MD, Chair, Children’s Oncology Group, The Children’s Hospital of Philadelphia, 3501 Civic Center Boulevard, CRTB 10060, Philadelphia, PA 19104;
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10
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Rotstein C, Cummings KM, Nicolaou AL, Lucey J, Fitzpatrick J. Nosocomial Infection Rates at an Oncology Center. Infect Control Hosp Epidemiol 2015; 9:13-9. [DOI: 10.1086/645727] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AbstractNosocomial infection rates were computed for 5,031 patients at an oncology center during a 20-month period. Twelve percent of the patients developed nosocomial infections, accounting for a total of 802 infections. The overall incidence of nosocomial infections during this study period was 6.27 infections per 1,000 patient days. The highest incidence of nosocomial infections was found in patients having acute myelogenous leukemia (30.49 infections per 1,000 patient days); bone and joint cancer (27.27 infections per 1,000 patient days); and liver cancer (26.58 infections per 1,000 patient days). The respiratory tract was the most common site of infection, followed by blood-stream, surgical wound, and urinary tract infections. Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and coagulase-negative staphylococci were most frequently implicated as pathogens. The distribution of specific types of infection according to underlying malignancy was also tabulated. These data provide nosocomial infection rates, common pathogens, and sites of infection for cancer patients, thus assisting in directing appropriate therapy for these patients.
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11
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Reitman AJ, Pisk RM, Gates JV, Ozeran JD. Serial procalcitonin levels to detect bacteremia in febrile neutropenia. Clin Pediatr (Phila) 2012; 51:1175-83. [PMID: 23034950 DOI: 10.1177/0009922812460913] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Our objective was to evaluate serial procalcitonin (PCT) levels compared with an initial PCT level at admission in predicting bacteremia in pediatric febrile neutropenic oncology patients. PROCEDURE Serum PCT levels were measured at admission (t0) and within 24 hours of admission (t1) in pediatric oncology patients presenting with fever and neutropenia. A blood culture was collected at t0 and monitored for 5 days for bacterial growth. PCT value of 0.5 ng/mL at either t0 or t1 was considered predictive for bacteremia. RESULTS PCT levels were significantly higher in children with positive blood cultures than with negative blood cultures. Serial PCT values mirrored t1 values. Serial PCT showed 76% specificity and negative predictive value of 93% in ruling out bacteremia. CONCLUSION Elevated PCT levels are predictive of bacteremia. Using serial PCT levels within 24 hours allowed a better prediction of bacteremia than the PCT level at t0.
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Affiliation(s)
- Aaron J Reitman
- University of California, San Francisco-Fresno, Fresno, CA 90027, USA.
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12
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Ha YE, Song JH, Kang WK, Peck KR, Chung DR, Kang CI, Joung MK, Joo EJ, Shon KM. Clinical factors predicting bacteremia in low-risk febrile neutropenia after anti-cancer chemotherapy. Support Care Cancer 2010; 19:1761-7. [DOI: 10.1007/s00520-010-1017-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Accepted: 09/28/2010] [Indexed: 01/09/2023]
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13
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Rosso R, Di Biagio A, Viscoli C. Infectious complications of cancer chemotherapy in HIV patients. Curr Infect Dis Rep 2010; 10:149-56. [PMID: 18462590 DOI: 10.1007/s11908-008-0026-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The outcome for HIV-infected patients with cancer has dramatically improved in the highly active antiretroviral therapy (HAART) era, probably due to improvements in immune status and bone marrow function that allow the possibility of increased drug-dose intensity with a higher complete remission rate. Although data regarding the optimal management of these cancers are lacking, current studies suggest that patients with HIV-associated malignancies could be treated using approaches similar to those for their counterparts in the general population (ie, with chemotherapy, radiation, and appropriate use of supportive measures). In the HAART era, the AIDS-related mortality rate has decreased by approximately 70%, and so the cause of the growing number of reports of cancers in HIV patients is unclear. Clearly, non-AIDS-defining malignancies account for more morbidity and mortality than AIDS-defining malignancies. Prevention strategies are needed to adequately deal with HIV-associated cancers in an aging and growing HIV-positive population.
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Affiliation(s)
- Raffaella Rosso
- Infectious Diseases Clinic, University of Genoa, San Martino Hospital, Largo R. Benzi 10, 16132, Genoa, Italy
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14
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da Silva ED, Koch Nogueira PC, Russo Zamataro TM, de Carvalho WB, Petrilli AS. Risk factors for death in children and adolescents with cancer and sepsis/septic shock. J Pediatr Hematol Oncol 2008; 30:513-8. [PMID: 18797197 DOI: 10.1097/mph.0b013e31815acae0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess risk factors for mortality in children and adolescents with cancer and sepsis/septic shock, admitted to intensive care unit. PATIENTS AND METHODS Retrospective study of a cohort of cancer and sepsis/septic shock patients (n=155) admitted to Oncological Pediatric Intensive Care Unit, between October 1998 and October 2001, with assessment of 12 potential risk factors for mortality by univariate analysis, followed by multivariable analysis. RESULTS Forty-seven out of 155 patients died (30.3%). In the present sample, after multivariable analysis, 3/12 variables proved to be statistically significant: respiratory infection [hazard ratio (HR)=2.3 and 95% confidence interval (CI)=1.3-4.2], duration of granulocytopenia (HR=2.4 and 95% CI=1.2-4.9), and number of organ dysfunction (HR=7.4 and 95% CI=2.6-21.3). CONCLUSIONS Our data suggest that mortality in Oncological Pediatric Intensive Care Unit is high and the main factors involved in prognosis are number of dysfunctional organs, respiratory infections, and duration of granulocytopenia; the mortality rises 7.4 times for each dysfunctional organ. We believe that prospective and multicenter studies are necessary to better characterize risk factors that are specific for cancer patients to produce a particular score to predict severity of complications and mortality of children with cancer.
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Affiliation(s)
- Elenice Domingos da Silva
- Oncologic Pediatric Intensive Care Unit, Instituto de Oncologia Pediátrica, Grupo de Apoio ao Adolescente e à Criança com Câncer, Universidade Federal de São Paulo, Sao Paulo, Brazil.
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Korones DN. Is routine chest radiography necessary for the initial evaluation of fever in neutropenic children with cancer? Pediatr Blood Cancer 2004; 43:715-7. [PMID: 15481080 DOI: 10.1002/pbc.20226] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- David N Korones
- University of Rochester Medcial Center, Rochester, NY 14642, USA.
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16
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Kostaridou S, Polychronopoulou S, Psarra K, Kapsimali V, Parcharidou A, Katevas P, Papasteriades C, Haidas S. Decrease of CD4 + and B-Lymphocyte Populations Is Not Associated with Severe Infectious Complications in Children with Acute Lymphoblastic Leukemia during Maintenance. Int J Hematol 2004; 80:354-60. [PMID: 15615261 DOI: 10.1532/ijh97.e0317] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The suppression of lymphopoiesis and immune competence during the maintenance phase in children with acute lymphoblastic leukemia (ALL) and the occurrence of infectious complications remain an unexplored area. In this study we assessed lymphocyte subpopulation disturbances during maintenance for childhood ALL along with the incidence, type, and severity of infections that occur during that period in the absence of neutropenia. Twenty-eight children (13 boys, 15 girls) with ALL aged 3-14 years (median 7 years) and treated according to the ALL-BFM 90/95 protocol were studied during maintenance for ALL. Complete white blood cell (WBC) counts and peripheral blood lymphocyte (PBL) analyses were performed. Major lymphocyte subsets (CD19+, CD3+CD4+, CD3-CD8+, CD3-CD16+CD56+, CD45RA-, CD45RO+) and markers of T-cell activation (CD25, CD38, CD69, HLA-DR) were analyzed with flow cytometry. Serum immunoglobulin G (IgG), IgA, and IgM levels were measured by a nephelometric assay. All infectious episodes during the study period were recorded in detail. Additionally, 41 age-matched immunocompetent children were used as controls. Absolute WBC counts (median, 3627/microL) and PBL counts (median, 1206/microL) were significantly below the age-adjusted control values (7400/microL and 2673/microL, respectively; P < .0001). B-lymphocyte, total CD4+, and memory CD4+ (CD4+CD45RO+) subsets were also significantly decreased (33/microL versus 377/microL [P < .0001], 531/microL versus 1045/microL [P < .01], and 80/microL versus 299/microL [P < .001], respectively). Significantly lower immunoglobulin levels were found in all patients. Twenty-two of the 28 patients presented with 74 episodes of a variety o minor infections (mostly respiratory viral [39], skin [7], and gastrointestinal [3]), none demanding prolonged hospital treat ment. Our findings demonstrate a profound immunosuppression throughout maintenance therapy in children with ALL tha has no major clinical impact in terms of increased incidence or severity of systemic infections.
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Affiliation(s)
- Stavroula Kostaridou
- Department of Pediatric Hematology/Oncology, Aghia Sophia Children's Hospital, Athens, Greece
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17
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MESH Headings
- Anemia, Aplastic/complications
- Anemia, Aplastic/drug therapy
- Bacterial Infections/prevention & control
- Child
- Child, Preschool
- Chronic Disease
- Granulocyte Colony-Stimulating Factor/therapeutic use
- Granulocyte-Macrophage Colony-Stimulating Factor/therapeutic use
- Hematopoietic Cell Growth Factors/therapeutic use
- Humans
- Infant
- Infant, Low Birth Weight
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/prevention & control
- Lymphoma, Non-Hodgkin/complications
- Lymphoma, Non-Hodgkin/drug therapy
- Neutropenia/complications
- Neutropenia/drug therapy
- Patient Selection
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/complications
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/drug therapy
- Randomized Controlled Trials as Topic
- Recombinant Proteins
- Retrospective Studies
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Affiliation(s)
- Thomas Lehrnbecher
- Department of Paediatric Haematology and Oncology, University of Frankfurt, Germany.
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18
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Mueller BU, Pizzo PA. Cytokines and biological response modifiers in the treatment of infection. Cancer Treat Res 1998; 96:201-22. [PMID: 9711401 DOI: 10.1007/978-0-585-38152-7_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- B U Mueller
- Pediatric Branch, National Cancer Institute, Bethesda, Maryland 20892, USA
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19
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Lehrnbecher T, Foster C, Vázquez N, Mackall CL, Chanock SJ. Therapy-induced alterations in host defense in children receiving therapy for cancer. J Pediatr Hematol Oncol 1997; 19:399-417. [PMID: 9329461 DOI: 10.1097/00043426-199709000-00001] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- T Lehrnbecher
- Department of Pediatrics, University of Würzburg, Germany
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20
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Muis N, Kamps WA, Dankert J. Prevention of infection in children with acute leukaemia. No major difference between total and selective bowel decontamination. Support Care Cancer 1996; 4:200-6. [PMID: 8739653 DOI: 10.1007/bf01682341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
To evaluate the effect of total bowel decontamination (TD) and selective bowel decontamination (SD) in a non-protective environment clinical and laboratory data of children treated for acute leukaemia between 1983 and 1991 were analysed retrospectively. From 1983 until 1989 34 patients [18 acute non-lymphoblastic leukaemia (ANLL) patients, 16 acute lymphoblastic leukaemia (ALL) patients] received TD and 31 patients (8 ANLL patients, 23 ALL patients) received SD from 1987 until 1991. TD consisted of colistin sulphate, neomycin, cephaloridine and amphotericin B orally as well as Orabase and sterilized food, while the patients were nursed in a single room. SD consisted of oral colistin sulphate, neomycin and amphotericin B. Those patients with ANLL were nursed in a single room; patients with ALL were nursed in a single room during remission induction therapy only. All patients except those with ANLL receiving TD received Pneumocystis carinii pneumonia prophylaxis with cotrimoxazole. Because the two groups were heterogeneous for diagnosis and chemotherapy the occurrence of fever (central body temperature at least 38.5 degrees C) and major infections (septicaemia of infections of the deep tissues or organs) were registered during periods of neutropenia (neutrophilic granulocytes < or = 500/mm3 for at least 8 days). Patients on TD had 55 periods of neutropenia, patients on SD 80. Patients on TD had 89.1 periods of fever/100 periods of neutropenia whereas patients on SD had 56.3. Also patients on TD had 27.3 major infections/100 periods of neutropenia whereas patients on SD had 11.3. Major infections predominantly consisted of septicaemia caused by gram-positive bacteria. We conclude that, in this study, TD in a non-protective environment does not offer better protection against major infections that SD in patients with ALL or ANLL.
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Affiliation(s)
- N Muis
- Paediatric Oncology Centre, University Hospital Groningen, The Netherlands
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21
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Lucas KG, Brown AE, Armstrong D, Chapman D, Heller G. The identification of febrile, neutropenic children with neoplastic disease at low risk for bacteremia and complications of sepsis. Cancer 1996. [DOI: 10.1002/(sici)1097-0142(19960215)77:4<791::aid-cncr27>3.0.co;2-v] [Citation(s) in RCA: 127] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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22
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Affiliation(s)
- C Viscoli
- Infectious Disease, National Institute for Cancer Research, Genova, Italy
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23
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Teinturier C, Hartmann O, Lemerle J, Benhamou E, Maraninchi D. Prevention of gram-positive infections in patients treated with high-dose chemotherapy and bone marrow transplantation: a randomized controlled trial of vancomycin. Pediatr Hematol Oncol 1995; 12:73-7. [PMID: 7703045 DOI: 10.3109/08880019509029531] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Between January 1986 and June 1988, 155 patients (73 children and 82 adults), who were candidates for bone marrow transplantation, were included in a randomized controlled trial (75 patients in vancomycin group and 80 patients in the group without vancomycin) to evaluate the efficiency of a short course of vancomycin (10 mg/kg i.v. every 6 hours, day-5 to +1) in decreasing the incidence of Gram-positive infections during aplasia after high-dose chemotherapy and bone marrow transplantation. There was no statistical difference in the occurrence of documented septicemia, documented coccus Gram-positive infections, or fever of unknown origins during aplasia in the 2 groups. Thus, short prophylactic treatment with vancomycin proved inefficient in reducing morbidity due to infection after high-dose chemotherapy and bone marrow transplantation.
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Affiliation(s)
- C Teinturier
- Department of Pediatric Oncology, Institut Gustave Roussy, Villejuif, France
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24
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Charak BS, Brown EG, Mazumder A. Protective effect of granulocyte-colony stimulating factor against amphotericin B-induced myelosuppression in vitro. Br J Haematol 1994; 88:693-8. [PMID: 7529537 DOI: 10.1111/j.1365-2141.1994.tb05106.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Amphotericin B causes suppression of bone marrow (BM) progenitor cells in vitro. Granulocyte colony stimulating factor (G-CSF) enhances the proliferation of myeloid cells. The present study defines the role of G-CSF in preventing amphotericin B-induced myelosuppression. G-CSF increased the proliferative potential of BM and protected against amphotericin B-induced myelosuppression if it was added to the medium during the early phase of exposure of BM to amphotericin B. Monoclonal antibodies to tumour necrosis factor-alpha (TNF) or interferon-gamma (IFN) inhibited the myelosuppression partially; simultaneous presence of both these antibodies completely abrogated this suppression, suggesting that both TNF alpha and IFN gamma were involved in amphotericin-induced myelosuppression. TNF- or IFN-induced suppression of BM was also inhibited by G-CSF. These data suggest that G-CSF prevents the amphotericin B-induced myelosuppression by antagonizing the suppressive effects of TNF and IFN and by enhancing the proliferative activity of BM.
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Affiliation(s)
- B S Charak
- Bone Marrow Transplantation Program, Georgetown University, Washington, D.C
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25
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Avril M, Hartmann O, Valteau-Couanet D, Brugieres L, Kalifa C, Lemerle J. Antiinfective prophylaxis with ceftazidime and teicoplanin in children undergoing high-dose chemotherapy and bone marrow transplantation. Pediatr Hematol Oncol 1994; 11:63-73. [PMID: 8155502 DOI: 10.3109/08880019409141902] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Sixty children treated for solid tumors with high-dose chemotherapy followed by bone marrow transplantation were randomly assigned to one of two antibiotic protocols. Group A received prophylaxis consisting of ceftazidime plus teicoplanin beginning before the onset of aplasia and fever; group B received exactly the same antibiotic regimen but beginning at the onset of fever. The two groups were compared in terms of the rate of septicemia, fever of unknown origin, the time-lapse before the appearance of septicemia, the sensitivity of the causative organisms to the antibiotics, the effect of the latter on the intestinal flora, and the rate of fungal infections. The incidence of septicemia was significantly lower in group A (6.6%) than in group B (24.0%), mainly due to the prevention of episodes of early onset. Similarly, the appearance of the first episode of fever was delayed in group A, and the overall duration was reduced. Amphotericin B was prescribed empirically with the same rule in both groups, but three children in group A did not require amphotericin B. The effect on the intestinal flora was similar in the two groups; it must, however, be closely monitored so that the presence of potential pathogens can be dealt with appropriately.
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Affiliation(s)
- M Avril
- Département de Pédiatrie, Institut Gustave Roussy, Villejuif, France
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26
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Viscoli C, Bruzzi P, Castagnola E, Boni L, Calandra T, Gaya H, Meunier F, Feld R, Zinner S, Klastersky J. Factors associated with bacteraemia in febrile, granulocytopenic cancer patients. The International Antimicrobial Therapy Cooperative Group (IATCG) of the European Organization for Research and Treatment of Cancer (EORTC). Eur J Cancer 1994; 30A:430-7. [PMID: 8018397 DOI: 10.1016/0959-8049(94)90412-x] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The objective of this investigation was to determine factors predictive of bacteraemia at presentation in febrile, granulocytopenic cancer patients in order to estimate the probability of bacteraemia in each patient, and to compare factors associated with a diagnosis of gram-positive or gram-negative bacteraemia. Retrospective analysis of two sets of data (derivation and validation sets) randomly obtained from a large prospective study was conducted in a multicentre study of febrile, granulocytopenic cancer patients admitted for empiric antibacterial therapy. Within the derivation set, prognostic factors (clinical and laboratory data) likely to be associated with a generic diagnosis of bacteraemia and with a specific diagnosis of gram-positive or gram-negative bacteraemia were analysed by means of three backward, stepwise, logistic regression analyses. The predictive probability of bacteraemia was calculated using the logistic equation. The discriminating ability of the model in predicting bacteraemia was evaluated in the derivation and validation sets using receiver-operating characteristic curves. The predictive probability of gram-positive or gram-negative bacteraemia was not calculated. In the derivation set, 157 of 558 episodes (28%) were microbiologically documented bacteraemias. Predicting factors were antifungal prophylaxis, duration of granulocytopenia before fever, platelet count, highest fever, shock and presence and location of initial signs of infection. The variables institution, antibacterial prophylaxis and underlying disease showed borderline associations with bacteraemia. Shock was associated with gram-negative bacteraemia, while signs of infection at catheter site were predictive of gram-positive bacteraemia. Quinolone prophylaxis was negatively associated with gram-negative bacteraemia. When tested in the validation set, the model was poorly predictive, although a small subgroup of episodes (representing only 16% of the total sample size) with low risk of bacteraemia was identified. Factors predictive of bacteraemia can be identified, with discrimination between gram-positive and gram-negative aetiology. Further studies are warranted in order to improve the discriminant ability of the model.
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Affiliation(s)
- C Viscoli
- National Institute for Cancer Research, Genova
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27
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Brook I, Ledney GD. Use of selective decontamination in the prevention of infection after accidental irradiation. A review. Prehosp Disaster Med 1993; 8:85-8. [PMID: 10155457 DOI: 10.1017/s1049023x00040073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Exposure to radiation induces a reduction in the number of gastrointestinal, anaerobic bacterial flora, and an increase in the number of Enterobacteriaceae that are associated with sepsis and mortality. Antimicrobials that suppress anaerobic flora have a deleterious effect on survival by promoting earlier enterobacterial sepsis. In contrast, in studies of animals and immunosuppressed patients, antimicrobials that inhibit gram-negative enteric bacteria and preserve the anaerobic flora have shown a beneficial effect by preventing bacterial translocation and fatal sepsis. The quinolone antimicrobials hold potential for therapy of endogenous and exogenous infection after irradiation.
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Affiliation(s)
- I Brook
- Experimental Hematology Department, Armed Forces Radiobiology Research Institute, Bethesda, MD 20899-5145, USA
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28
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Petrilli AS, Bianchi A, Kusano E, Melaragno R, Naspitz C, Mendonça JDS, Pizzo PA. Fever and granulocytopenia in children with cancer: a study of 299 episodes with two treatment protocols in Brazil. MEDICAL AND PEDIATRIC ONCOLOGY 1993; 21:356-61. [PMID: 8492751 DOI: 10.1002/mpo.2950210509] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In Brazil, 226 children with cancer presenting 299 episodes of fever and neutropenia (< or = 500/mm3) were treated with two consecutive empirical regimens. Regimen I-Cefoxitin Amikacin-Carbenicillin; and Regimen II Ceftriaxone-Amikacin. 67.0% of the patients had leukemias or lymphomas, documented infections occurred in 47.2%, superinfections occurred in 18.7% (Reg. I) and 17.8% (Reg. II) of the episodes. The most common agents identified in Reg. I and Reg. II were, respectively, Gram negative rods (55.0%) and Gram positive cocci (52.6%). The overall rate of success with modifications (Amphotericin B, Vancomycin, Clindamycin, Metronidazole) was higher in Reg. II (93.0%) than in Reg. I (84.0%). This study shows that the appropriate formula to maximize the successful treatment of children with cancer, fever and neutropenia in developing nations includes adherence to established principles of supportive care, utilizing the optimal antibiotic agents available in the country. It is important to promote the necessary modifications along the treatment having in mind the high index of resistant agents.
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Affiliation(s)
- A S Petrilli
- Pediatrics Department, Paulista Medical School, São Paulo, Brazil
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29
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Groll A, Renz S, Gerein V, Schwabe D, Katschan G, Schneider M, Hübner K, Kornhuber B. Fatal haemoptysis associated with invasive pulmonary aspergillosis treated with high-dose amphotericin B and granulocyte-macrophage colony-stimulating factor (GM-CSF). Mycoses 1992; 35:67-75. [PMID: 1435849 DOI: 10.1111/j.1439-0507.1992.tb00822.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Opportunistic pulmonary infections are a leading cause of morbidity and mortality in patients with chemotherapeutically treated neoplasias. With increasingly aggressive cytotoxic regimens causing prolonged neutropenia, the risk of systemic mycoses and in particular of invasive pulmonary aspergillosis has increased. We review the case of a 10-year-old child suffering from relapsed lymphoblastic leukaemia and from high-dose amphotericin B-treated invasive pulmonary aspergillosis acquired during long-standing neutropenia in the initial phase of remission induction chemotherapy. The patient died in remission after GM-CSF-induced bone marrow recovery and clinical and radiological improvement with stable plasmatic coagulation and normal thrombocyte count. Peracute massive pulmonary bleeding caused by the simultaneous arrosion of a greater pulmonary artery and a lobar bronchus by a liquefactive fungal focus was responsible. In patients with chemotherapeutically induced neutropenia and invasive aspergillosis, bone marrow recovery may lead to the liquefaction of pulmonary foci, and, in view of the well-known vasotropic nature of the infection, to a potentially lethal arrosion bleeding. With the emerging use of colony-stimulating factors for shortening and overcoming neutropenia, this so far rare complication may become of increasing importance.
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Affiliation(s)
- A Groll
- Department of Pediatrics, J. W. Goethe-University, Frankfurt/Main, Germany
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30
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Pizzo PA, Rubin M, Freifeld A, Walsh TJ. The child with cancer and infection. I. Empiric therapy for fever and neutropenia, and preventive strategies. J Pediatr 1991; 119:679-94. [PMID: 1941374 DOI: 10.1016/s0022-3476(05)80281-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- P A Pizzo
- Pediatric Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
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31
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Zülfikar B, Devecioğlu O, Anak S, Ovali F, Gedikoğlu G. The efficacy of mezlocillin-amikacin combination in febrile neutropenic children with oncologic disease. J Chemother 1991; 3:250-4. [PMID: 1779260 DOI: 10.1080/1120009x.1991.11739100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The efficacy of mexlocillin-amikacin combination as empirical therapy for febrile neutropenic patients was studied in 30 children (21 males, 9 females) with various oncologic diseases aged 1-15 years (mean age 7.3 +/- 4.4) in the Istanbul Medical School, Oncologic Disease Research and Treatment Center, and Department of Pediatric Hematology-Oncology between January 1 and May 31, 1988. The response rate was 76.6%. Profound persistent granulocytopenia (fewer than 100 ml) was present in 70% of the patients. In 63.3% of patients, the infections were microbiologically documented (60%) Gram(+) and 40% Gram(-). The combination was well tolerated with hepatic and/or renal disturbances in 8 cases (26.6%). We conclude that mezlocillin-amikacin is an effective empirical combination in the initial treatment of infections in febrile neutropenic children with various oncologic diseases.
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Affiliation(s)
- B Zülfikar
- Istanbul University, Istanbul Medical School, Türkiye
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32
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Affiliation(s)
- J E Gootenberg
- Department of Pediatrics, Georgetown University School of Medicine, Washington, DC
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33
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Carstensen H, Widding E, Storm K, Ostergaard E, Herlin T. Hepatosplenic candidiasis in children with cancer. Three cases in leukemic children and a literature review. Pediatr Hematol Oncol 1990; 7:3-12. [PMID: 2204407 DOI: 10.3109/08880019009034316] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Three children with acute leukemia presented with prolonged fever and neutropenia after cytostatic therapy, which was followed by abdominal pain, hepatomegaly, and hepatic dysfunction with raised serum alkaline phosphatase. Abdominal CT scan and ultrasound demonstrated multiple small lesions compatible with the hepatosplenic candidiasis syndrome. Liver biopsies showed microabscesses with a granulomatous appearance, but evidence of yeasts and pseudohyphae was present in 1 case only. Cultures were negative. Treatment with amphotericin B and 5-fluorocytosine was successful in two children. At autopsy, one child had signs of active infection. We reviewed the literature on 27 children with hepatosplenic candidiasis. Abdominal symptomatology and prolonged fever, despite antibiotic therapy, in a patient with previous or present neutropenia after cytotoxic exposure, should lead to a careful evaluation, including noninvasive imaging studies, open liver biopsy, and prompt aggressive antifungal treatment, the response to which requires close follow-up.
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Affiliation(s)
- H Carstensen
- Department of Pediatrics, Rigshospitalet, University Hospital, Copenhagen, Denmark
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34
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Abstract
Few details exist on the course of mumps during cytostatic treatment. We therefore describe our observations on the course of mumps seen between 1974 and 1988 in eight children suffering from acute lymphocytic leukaemia (ALL). Our data suggest that in malignant disease the course is rarely severe and that the infection often remains subclinical, as in healthy children. Mumps was accidentally diagnosed by routine lumbar puncture in four of the eight patients. Literature data suggest that the intrinsic low cytopathological effect of the virus, together with a parallelism between T cell response and clinical severity, may explain the usual mild course in immunodepressed patients, contrasting with the severe course of measles and Varicella zoster.
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Affiliation(s)
- A W de Boer
- Centre for Paediatric Oncology, University Hospital Nijmegen, The Netherlands
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35
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Abstract
Abnormalities of the production of interleukin-2 (IL-2) may play an important role in the immunologic dysfunction observed in pediatric leukemia patients. For an evaluation of the ability of lymphocytes from leukemic children to produce this cytokine, the production of IL-2 by mitogen-stimulated peripheral blood mononuclear cells was determined in children with acute leukemia at the time of diagnosis, during clinical remission, and at the time of relapse. Of 16 patients, 11 (69%) with either acute lymphoblastic leukemia or acute nonlymphoblastic leukemia at the time of diagnosis had IL-2 production levels above the highest level observed in control subjects, and all but one had values above the control mean. Three of five treated patients had elevated IL-2 production at the time of bone marrow relapse. In addition, of 37 patients examined during clinical remission (both during chemotherapy and after the completion of maintenance chemotherapy), five had IL-2 production values above the control range and four of these five patients subsequently had relapses, compared with only one relapse in the remaining 32 patients with normal or below-normal levels of IL-2 production. These results demonstrate an increased ability to produce IL-2 by many patients with acute leukemia, both at the time of diagnosis and at relapse. Elevated IL-2 production may represent an immunologic response to leukemic cells and in some patients may provide a marker for persistent leukemia.
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Affiliation(s)
- D Ridgway
- Division of Hematology/Oncology, Doernbecher Memorial Hospital for Children, Portland, OR 97201
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36
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De Conno F, Ripamonti C, Sbanotto A, Ventafridda V. Issues in symptom control. Part 4. Oral complications in patients with advanced cancer. J Pain Symptom Manage 1989; 4:20-30. [PMID: 2649619 DOI: 10.1016/0885-3924(89)90060-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Disturbances caused by lesions of the oral cavity play an important part in the alteration of the quality of life of cancer patients. The main complications affecting the oral cavity are infections (fungal, viral, bacterial), neutropenic ulcers, drug-induced stomatitis, dry mouth, and taste alteration. Most of the information available about these entities has been acquired in the cancer patient without advanced disease. The little knowledge about the epidemiology and physiopathology of such lesions in the advanced phase of cancer is presented, and approaches to management are suggested.
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37
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Fievre et infection chez les patients neutropeniques. Etude de 138 épisodes. Med Mal Infect 1988. [DOI: 10.1016/s0399-077x(88)80197-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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38
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Barrett AP. Chronic indolent orofacial herpes simplex virus infection in chronic leukemia: a report of three cases. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1988; 66:387-90. [PMID: 3050711 DOI: 10.1016/0030-4220(88)90251-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Orofacial mucocutaneous infections caused by herpes simplex virus (HSV) may exhibit a distinct chronic indolent pattern of behavior in some immunosuppressed patients as opposed to the more familiar aggressive patterns. Three patients with chronic leukemia who illustrate this chronic indolent pattern are presented. These cases should alert the clinician to the variable clinical appearance that HSV may adopt in the immunosuppressed patient.
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Affiliation(s)
- A P Barrett
- Westmead Hospital Dental Clinical School, New South Wales, Australia
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39
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Abstract
Infectious complications in children with acute leukemias are reviewed as to incidence, predisposing factors, microbiologic etiologies and treatment. Principles of antimicrobiologic therapy are presented for bacterial, fungal, viral, and protozoal infections seen in children with cancer. Prevention of infection is also discussed.
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Affiliation(s)
- E A Albano
- Pediatric Hematology/Oncology, Children's Hospital National Medical Center, Washington, D.C
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40
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Rotstein C, Cummings KM, Nicolaou AL, Lucey J, Fitzpatrick J. Nosocomial Infection Rates at an Oncology Center. Infect Control Hosp Epidemiol 1988. [DOI: 10.2307/30144129] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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41
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Abstract
There are some differences between pediatric and adult cancer patients in terms of the problem of infection but it is doubtful whether such discrepancies justify different therapeutic approaches. For example, according to the results of EORTC trial IV, children seem to show lower overall (3% vs 19%) and infectious (2% vs 8%) mortality than adults, probably due to differences in underlying diseases and to a basic better physical integrity. Central intravenous catheters appear to be indispensable in the modern management of neoplastic diseases, especially in pediatric oncology. A prospective study performed in our institution on 157 Broviac catheters, has shown: 1. Of all microbiologically documented infections, occurring in children undergoing cancer chemotherapy and radiotherapy, 27% are related to the catheter 2. Gram-positive cocci are the leading pathogens (78%) of such infections 3. Catheter-related infections often occur in non-neutropenic patients 4. Such infections can be successfully treated without removing the intravenous device. The experience of the EORTC Cooperative Group and of other centers throughout the world shows that gram-positive cocci are increasingly being isolated as the cause of infections in cancer patients. This phenomenon is probably multifactorial in origin and appears to be more evident in pediatrics. For example, in our institution, during the last 5 years gram-positive organisms have caused 69% of all bacteremias. Moreover, these organisms, while responding poorly to the presently used empirical antibiotic regimens, seem not to be as aggressive as gram-negative organisms and cause lower mortality. There is therefore controversy over whether or not to include anti-gram-positive coverage in early empirical regimens. In our institution, a pilot study comparing ceftazidime + amikacin (C + A) and ceftazidime + vancomycin (C + V) seems to show an overall advantage for C + V. This advantage, however, is not statistically significant. One finding to be pointed out is that five of ten staphylococcal infections failed to respond to C + V and that in these cases a third antibiotic had to be added. Therefore, it is likely that, at least in institutions in which methicillin-resistant staphylococci are prevalent, a triple antibiotic empirical regimen will provide the best coverage, but this can result in overtreatment. However, only prospective, randomized and multicenter trials will be able to answer such questions definitely.
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Affiliation(s)
- C Viscoli
- Department of Infectious Diseases, University of Genova, Italy
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42
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43
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Mason CA. Septic shock. JOURNAL OF THE ASSOCIATION OF PEDIATRIC ONCOLOGY NURSES 1987; 4:25-31. [PMID: 3437402 DOI: 10.1177/104345428700400305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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44
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Abstract
Naproxen was used as an antipyretic agent in febrile pediatric cancer patients with evidence of active malignant disease. Sixteen children with leukemia and lymphoma who had fever for more than 72 hours were given naproxen to control fever. Their ages ranged from 16 months to 17 years. There were ten female and six male patients. Their temperature was greater than 38.3 degrees C and the leukocyte count ranged from 400/microliters to 33.3 X 10(3)/microliters, with an absolute neutrophil count (ANC) from 0 to 4514/microliters. The children had no evidence of infection by clinical or laboratory evaluations. All patients were receiving triple antibiotics when naproxen was started. Fourteen patients responded to naproxen with complete lysis of fever within 6 hours of initiation of treatment. Two patients did not respond to naproxen, but proved to have culture-positive infections. There were no side effects from the drug. Naproxen is an effective antipyretic in patients with cancer. It may be useful as a means of differentiating fever secondary to active malignant disease from that due to infection.
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45
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Abstract
This study reviewed 431 episodes of septicemia occurring in 356 patients with cancer at Memorial Sloan-Kettering Cancer Center during 1982. The most frequent organisms causing 273 episodes in 239 non-neutropenic patients were Escherichia coli (20 percent), Staphylococcus aureus (13 percent), polymicrobic (12 percent), Pseudomonas species (8 percent), Klebsiella species (7 percent), Candida species (7 percent), Bacteroides species (6 percent), Enterobacter species (4 percent), and Clostridium species (4 percent). The overall mortality was 31 percent (21 percent with adequate therapy; 50 percent with inadequate therapy). The most frequent organisms causing 158 episodes in 117 neutropenic patients were polymicrobic (21 percent), E. coli (16 percent), Klebsiella species (15 percent), Pseudomonas species (8 percent), Candida species (6 percent), S. aureus (6 percent), Streptococcus faecalis (5 percent), S. epidermidis (4 percent), and Corynebacterium CDC-JK (3 percent). The overall mortality was 52 percent (36 percent with adequate therapy; 88 percent with inadequate therapy). Since a review a decade ago, the spectrum of organisms changed in that the gram-positive organisms, S. faecalis, S. epidermidis, and C. CDC-JK, emerged as important pathogens. Neutropenic patients had a high incidence (42 percent) of septicemia due to multiple organisms, occurring concurrently or sequentially. The overall mortality of these patients was exceptionally high (80 percent). In contrast, the overall mortality of neutropenic patients with single-organism septicemia was comparable to that of non-neutropenic patients with single-organism septicemia (37 percent versus 29 percent).
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46
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Abstract
Infection is a major threat to patients with neutropenia, particularly those with haematological malignancies who are undergoing chemotherapy. Early use of an empirical antibiotic regimen with the broadest possible spectrum of activity is recommended until culture data can guide the choice. A standard combination in many centres is an amino-glycoside and a semisynthetic penicillin with antipseudomonal activity or a cephalosporin. However, no regimen can adequately cover all potential pathogens and in these patients, who are exposed to many toxic insults, the choice of antibiotics may significantly increase the incidence of side effects, particularly nephrotoxicity. There has, therefore, been considerable interest in simpler, less toxic (and less expensive) regimens and the concept of monotherapy has been explored. Although recent studies using ceftazidime alone have supported this as an effective approach, there remain several issues to resolve; and on a more cautionary note preliminary results from the latest EORTC study, which recruited more than 1200 patients, suggest that in Gram-negative bacteraemia, conventional combination therapy remains the treatment of choice in neutropenia. While monotherapy is attractive in an environment of low drug resistance when exposure to third generation cephalosporins is infrequent, this is rarely the case. In addition, the widespread use of tunnelled catheters for venous access had led to an increase in Gram-positive infections, and the more intensive immunosuppression to the emergence of fungal infections. Although these tend not to be rapidly fatal, their presence must be considered in designing treatment strategies. The influence of the host and treatment on the type of infection and the relative merits of the differing concepts in therapy are explored in detail in this article.
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Affiliation(s)
- A C Newland
- Department of Haematology, London Hospital, Whitechapel
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Felix CA, Davey RJ. Massive acute hemolysis secondary to Clostridium perfringens sepsis in a recently transfused oncology patient with multiple alloantibodies. MEDICAL AND PEDIATRIC ONCOLOGY 1987; 15:42-4. [PMID: 3561329 DOI: 10.1002/mpo.2950150110] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Sepsis with clostridia species is seen infrequently in oncology patients, and the massive acute intravascular hemolysis known to be associated with these organisms is rare. The urgency of making the diagnosis of clostridial sepsis is imperative since the course is rapidly fatal if untreated. We describe a patient with metastatic adenocarcinoma of the pancreas, known to have recent transfusions as well as multiple red cell alloantibodies, who developed massive nonimmunologic hemolysis associated with Clostridium perfringens sepsis. Because the hemolysis of C. perfringens sepsis can mimic that of a severe delayed hemolytic transfusion reaction, care must be taken to differentiate these conditions, especially in view of the frequency of transfusion in these patients as well as their predisposition to develop disseminated infections.
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48
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Abstract
We report two instances of Hansen's disease as a complication of lymphoma. Although patients with leprosy may be at risk for the development of neoplasia, the converse has only rarely been reported. Nonetheless, granulomatous lesions in patients with lymphoreticular malignancy should suggest appropriate studies to rule out Hansen's disease, as illustrated by the cases detailed herein.
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49
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Guerra IC, Shearer WT. Environmental control in management of immunodeficient patients: experience with "David". CLINICAL IMMUNOLOGY AND IMMUNOPATHOLOGY 1986; 40:128-35. [PMID: 3521965 DOI: 10.1016/0090-1229(86)90076-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Environmental control in managing patients with immunodeficiency ranges from the exceedingly complex to the relatively simple. At one end of the spectrum is the total isolation technology applied to David, the "Bubble Boy" who lived his entire life behind sterile plastic barriers. At the other end of the spectrum is the simpler technology applied to patients receiving bone marrow transplants who are maintained in ordinary private hospital rooms and attended by personnel who merely observe handwashing precautions. Most properly performed and controlled studies of the use of special isolation procedures to reduce infections derive from patients receiving bone marrow transplants for conditions of aplastic anemia and leukemia or patients receiving chemotherapy for malignancy. The design of isolation procedures for immunodeficient patients borrows from these studies because of the relatively small number of immunodeficient patients. These studies have shown that laminar airflow rooms produce a significantly lower incidence of infections but may not change the mortality of all patients. Also, protective isolation has clearly reduced the incidence and severity of graft-versus-host disease in transplanted patients with aplastic anemia. Recently there has been a trend away from strict isolation procedures because careful studies have indicated that host rather than acquired pathogens are responsible for at least 85% of infections in these special patients. Also, the human stress of prolonged isolation is becoming increasingly recognized. The complex and expensive isolation techniques that were used in David's case are no longer being utilized in immunodeficient subjects, partly because new transplantation technology has made it possible to cross histocompatibility barriers, obviating the need for permanent isolation.
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50
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La ceftazidime associée à la netilmicine dans le traitement de première intention des épisodes fébriles chez les enfants en aplasie médullaire aprés chimiothérapie. Med Mal Infect 1986. [DOI: 10.1016/s0399-077x(86)80313-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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