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Slatnick LR, Miller K, Scott HF, Loi M, Esbenshade AJ, Franklin A, Lee-Sherick AB. Serum lactate is associated with increased illness severity in immunocompromised pediatric hematology oncology patients presenting to the emergency department with fever. Front Oncol 2022; 12:990279. [PMID: 36276165 PMCID: PMC9583361 DOI: 10.3389/fonc.2022.990279] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 09/19/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Determining which febrile pediatric hematology/oncology (PHO) patients will decompensate from severe infection is a significant challenge. Serum lactate is a well-established marker of illness severity in general adult and pediatric populations, however its utility in PHO patients is unclear given that chemotherapy, organ dysfunction, and cancer itself can alter lactate metabolism. In this retrospective analysis, we studied the association of initial serum lactate in febrile immunosuppressed PHO patients with illness severity, defined by the incidence of clinical deterioration events (CDE) and invasive bacterial infection (IBI) within 48 hours. Methods Receiver operating characteristic (ROC) curves were reported using initial lactate within two hours of arrival as the sole predictor for CDE and IBI within 48 hours. Using a generalized estimating equations (GEE) approach, the association of lactate with CDE and IBI within 48 hours was tested in univariate and multivariable analyses including covariates based on Quasi-likelihood under Independence Model Criterion (QIC). Additionally, the association of lactate with secondary outcomes (i.e., hospital length of stay (LOS), intensive care unit (PICU) admission, PICU LOS, non-invasive infection) was assessed. Results Among 897 encounters, 48 encounters had ≥1 CDE (5%), and 96 had ≥1 IBI (11%) within 48 hours. Elevated lactate was associated with increased CDE in univariate (OR 1.77, 95%CI: 1.48-2.12, p<0.001) and multivariable (OR 1.82, 95%CI: 1.43-2.32, p<0.001) analyses, longer hospitalization (OR 1.15, 95%CI: 1.07-1.24, p<0.001), increased PICU admission (OR 1.68, 95%CI: 1.41-2.0, p<0.001), and longer PICU LOS (OR 1.21, 95%CI: 1.04-1.4, p=0.01). Elevated lactate was associated with increased IBI in univariate (OR 1.40, 95%CI: 1.16-1.69, p<0.001) and multivariable (OR 1.49, 95%CI: 1.23-1.79, p<0.001) analyses. Lactate level was not significantly associated with increased odds of non-invasive infection (p=0.09). The QIC of the model was superior with lactate included for both CDE (305 vs. 325) and IBI (563 vs. 579). Conclusions These data demonstrated an independent association of elevated initial lactate level and increased illness severity in febrile PHO patients, suggesting that serum lactate could be incorporated into future risk stratification strategies for this population.
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Affiliation(s)
- Leonora Rose Slatnick
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
- *Correspondence: Leonora Rose Slatnick,
| | - Kristen Miller
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
| | - Halden F. Scott
- Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
| | - Michele Loi
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
- Department of Pediatrics, Division of Critical Care Medicine, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
| | - Adam J. Esbenshade
- Department of Pediatrics, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, United States
| | - Anna Franklin
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
| | - Alisa B. Lee-Sherick
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
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Cennamo F, Masetti R, Largo P, Argentiero A, Pession A, Esposito S. Update on Febrile Neutropenia in Pediatric Oncological Patients Undergoing Chemotherapy. CHILDREN 2021; 8:children8121086. [PMID: 34943282 PMCID: PMC8700030 DOI: 10.3390/children8121086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/12/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
Febrile neutropenia (FN) is a common complication of chemotherapy in oncological children and one of the most important causes of morbidity and mortality in these patients. The early detection of a bacteremia and the rapid therapeutic intervention are crucial to improve the outcome. We analyzed the literature in order to clarify the epidemiology of FN in children undergoing chemotherapy, the specific factors associated with a negative outcome, the most common etiology, and the value of biological markers as a tool to make an early diagnosis or to monitor the evolution of the infection. Several studies have tried to identify specific factors that could help the clinician in the detection of an infection and in its microbiological identification. However, due to the heterogenicity of the available studies, sufficient evidence is lacking to establish the role of these risk factors in clinical practice and future research on this topic appear mandatory. Determinations of risk factors, etiology, and markers of febrile episodes in these patients are complicated by the characteristics of the underlying illness and the effects of treatments received. Although some studies have tried to develop an evidence-based guideline for the empiric management of FN in pediatrics, validated predictive scores and algorithms are still lacking and urgently needed.
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Affiliation(s)
- Federica Cennamo
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Riccardo Masetti
- Pediatric Oncology and Hematology Unit “Lalla Seragnoli”, Pediatric Unit-IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.M.); (A.P.)
| | - Prisca Largo
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Andrea Pession
- Pediatric Oncology and Hematology Unit “Lalla Seragnoli”, Pediatric Unit-IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.M.); (A.P.)
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
- Correspondence: ; Tel.: +39-0521-704-790
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RODRIGUES I, NASCIMENTO L, PIMENTA AC, RAIMUNDO S, CONDE B, FERNANDES A. [Neutropenic Fever in Lung Cancer: Clinical Aspects Related to Mortality and Antibiotic Failure]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2021; 24:764-769. [PMID: 34802207 PMCID: PMC8607283 DOI: 10.3779/j.issn.1009-3419.2021.102.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Lung cancer (LC) is the leading cause of cancer death. Patients treated with chemotherapy are at risk of developing chemotherapy-induced febrile neutropenia (FN), a potentially life-threatening complication. The aims of this study were (1) to characterize FN admissions of patients with LC in a pulmonology department, and (2) to determine associations between patient profiles, first-line antibiotic failure (FLAF) and mortality. METHODS Retrospective observational case-series, based on the analysis of medical records of LC patients that required hospitalization due to chemotherapy-induced FN. RESULTS A total of 42 cases of FN were revised, corresponding to 36 patients, of which 86.1% were male, with a mean age of 66.71±9.83 years. Most patients had a performance status (PS) equal or less than 1, and metastatic disease was present in 40.5% (n=17). Respiratory tract infections accounted for 42.9% (n=18) of FN cases, and multidrug-resistant Staphylococcus aureus was the most isolated agent. The mortality rate was 16.7% (n=7), and the FLAF was 26.2% (n=11). Mortality was associated with a PS≥2 (P=0.011), infection by a Gram-negative agent (P=0.001) and severe anemia (P=0.048). FLAF was associated with longer hospitalizations (P=0.020), PS≥2 (P=0.049), respiratory infections (P=0.024), and infection by a Gram-negative (P=0.003) or multidrug-resistant agent (P=0.014). CONCLUSIONS Lower PS, severe anemia, and infections by Gram-negative or multi-resistant agents seem to be associated with worse outcomes in FN patients.
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Affiliation(s)
- Inês RODRIGUES
- Pulmonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal,Inês RODRIGUES, E-mail:
| | - Luísa NASCIMENTO
- Pulmonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Ana Cláudia PIMENTA
- Pulmonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Sara RAIMUNDO
- Pulmonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Bebiana CONDE
- Pulmonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Ana FERNANDES
- Pulmonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
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Suwanpakdee D, Prasertsin W, Traivaree C, Rujkijyanont P. Serum Lactate: A Predictor of Septic Shock in Childhood Cancers with Febrile Neutropenia. Glob Pediatr Health 2021; 8:2333794X211022711. [PMID: 34104707 PMCID: PMC8170332 DOI: 10.1177/2333794x211022711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/14/2021] [Indexed: 12/22/2022] Open
Abstract
Early recognition and management are the key elements to prevent febrile
neutropenia associated mortality. The prospective observational study aimed to
investigate prognostic accuracy of serum lactate to predict septic shock within
48 hours among hemodynamically stable children with febrile neutropenia. In all,
99 pediatric oncology patients who developed febrile neutropenia were enrolled
in the study. Clinical information during 48 hours and serum lactate at the time
of enrollment were analyzed. Among 99 participating patients, 10 developed
septic shock and 4 of those expired. No significant difference was found of
patients’ baseline characteristics and basic laboratory parameters between
patients with and without septic shock. Serum lactate was significantly elevated
among patients developing septic shock (P-value < .001) and
those who expired (P-value .002). Receiver operating
characteristic (ROC) curve was created to identify the best cutoff value for
initial serum lactate associated with the development of septic shock within
48 hours. Baseline serum lactate more than 2.5 mmol/L showed the largest area
under the ROC curve to predict the septic shock development within 48 hours (ROC
area, 0.90; 95% confidence interval [CI], 0.81-0.98), with sensitivity,
specificity, negative predictive value, and accuracy of 80.0%, 92.1%, 97.6%, and
90.9%, respectively. Serum lactate level determined early at the time of febrile
neutropenia was an effective surrogate marker for developing septic shock within
48 hours among hemodynamically stable, pediatric oncology patients. The level
more than 2.5 mmol/L was the best threshold to start preemptive aggressive
hemodynamic monitoring and prompt treatment to ensure adequate tissue
perfusion.
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Kochanek M, Schalk E, von Bergwelt-Baildon M, Beutel G, Buchheidt D, Hentrich M, Henze L, Kiehl M, Liebregts T, von Lilienfeld-Toal M, Classen A, Mellinghoff S, Penack O, Piepel C, Böll B. Management of sepsis in neutropenic cancer patients: 2018 guidelines from the Infectious Diseases Working Party (AGIHO) and Intensive Care Working Party (iCHOP) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol 2019; 98:1051-1069. [PMID: 30796468 PMCID: PMC6469653 DOI: 10.1007/s00277-019-03622-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/17/2019] [Indexed: 02/06/2023]
Abstract
Sepsis and septic shock are major causes of mortality during chemotherapy-induced neutropenia for malignancies requiring urgent treatment. Thus, awareness of the presenting characteristics and prompt management is most important. Improved management of sepsis during neutropenia may reduce the mortality of cancer therapies. However, optimal management may differ between neutropenic and non-neutropenic patients. The aim of the current guideline is to give evidence-based recommendations for hematologists, oncologists, and intensive care physicians on how to manage adult patients with neutropenia and sepsis.
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Affiliation(s)
- Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany.
| | - E Schalk
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - M von Bergwelt-Baildon
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Medical Department III, University Medical Center & Comprehensive Cancer Center Munich, Munich, Germany
| | - G Beutel
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department for Hematology, Hemostasis, Oncology and Stem Cell Transplantation Hannover Medical School, Hannover, Germany
| | - D Buchheidt
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Hematology and Oncology, Mannheim University Hospital, Mannheim, Germany
| | - M Hentrich
- Department of Medicine III - Hematology and Oncology, Red Cross Hospital, Munich, Germany
| | - L Henze
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Medicine, Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | - M Kiehl
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Internal Medicine I, Clinic Frankfurt (Oder), Frankfurt, Germany
| | - T Liebregts
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Bone Marrow Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - M von Lilienfeld-Toal
- Department for Hematology and Medical Oncology, University Hospital Jena, Jena, Germany
| | - A Classen
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - S Mellinghoff
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - O Penack
- Department for Hematology, Oncology and Tumorimmunology, Campus Virchow Clinic, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - C Piepel
- Department of Hematology, Oncology and Infectious Diseases, Klinikum Bremen-Mitte, Bremen, Germany
| | - B Böll
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
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Critical Care Management: Sepsis and Disseminated and Local Infections. CRITICAL CARE OF THE PEDIATRIC IMMUNOCOMPROMISED HEMATOLOGY/ONCOLOGY PATIENT 2019. [PMCID: PMC7123939 DOI: 10.1007/978-3-030-01322-6_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Local and systemic infections are a significant cause of morbidity and mortality among immunocompromised children, including but not limited to patients with hematologic and solid malignancies, congenital or acquired immunodeficiencies, or hematopoietic cell or solid organ transplantation patients. Progression to septic shock can be rapid and profound and thus requires specific diagnostic and treatment approaches. This chapter will discuss the diagnosis and the initial hemodynamic management strategies of septic shock in immunocompromised children, including strategies to improve oxygen delivery, reduce metabolic demand, and monitor hemodynamic response to resuscitation. This chapter also discusses strategies to reverse septic shock pathobiology, including the use of both empiric and targeted anti-infective strategies and pharmacologic and cell therapy-based immunomodulation. Specific consideration is also paid to the management of high-risk subpopulations and the care of septic shock patients with resolving injury.
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Klastersky J, Paesmans M, Aoun M, Georgala A, Loizidou A, Lalami Y, Dal Lago L. Clinical research in febrile neutropenia in cancer patients: Past achievements and perspectives for the future. World J Clin Infect Dis 2016; 6:37-60. [DOI: 10.5495/wjcid.v6.i3.37] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 12/02/2015] [Accepted: 06/03/2016] [Indexed: 02/06/2023] Open
Abstract
Febrile neutropenia (FN) is responsible for significant morbidity and mortality. It can also be the reason for delaying or changing potentially effective treatments and generates substantial costs. It has been recognized for more than 50 years that empirical administration of broad spectrum antibiotics to patients with FN was associated with much improved outcomes; that has become a paradigm of management. Increase in the incidence of microorganisms resistant to many antibiotics represents a challenge for the empirical antimicrobial treatment and is a reason why antibiotics should not be used for the prevention of neutropenia. Prevention of neutropenia is best performed with the use of granulocyte colony-stimulating factors (G-CSFs). Prophylactic administration of G-CSFs significantly reduces the risk of developing FN and consequently the complications linked to that condition; moreover, the administration of G-CSF is associated with few complications, most of which are not severe. The most common reason for not using G-CSF as a prophylaxis of FN is the relatively high cost. If FN occurs, in spite of prophylaxis, empirical therapy with broad spectrum antibiotics is mandatory. However it should be adjusted to the risk of complications as established by reliable predictive instruments such as the Multinational Association for Supportive Care in Cancer. Patients predicted at a low level of risk of serious complications, can generally be treated with orally administered antibiotics and as out-patients. Patients with a high risk of complications should be hospitalized and treated intravenously. A short period of time between the onset of FN and beginning of empirical therapy is crucial in those patients. Persisting fever in spite of antimicrobial therapy in neutropenic patients requires a special diagnostic attention, since invasive fungal infection is a possible cause for it and might require the use of empirical antifungal therapy.
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Møller T, Moser C, Adamsen L, Rugaard G, Jarden M, Bøtcher TS, Wiedenbein L, Kjeldsen L. Early warning and prevention of pneumonia in acute leukemia by patient education, spirometry, and positive expiratory pressure: A randomized controlled trial. Am J Hematol 2016; 91:271-6. [PMID: 26661344 PMCID: PMC5067626 DOI: 10.1002/ajh.24262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 11/19/2015] [Accepted: 11/28/2015] [Indexed: 11/13/2022]
Abstract
Long‐lasting neutropenia associated with acute myeloid leukemia (AML) and its treatment gives rise to a high risk of pneumonia. The use of broad‐spectrum antibiotic prophylaxis during outpatient management has not completely protected patients against admission due to infections and neutropenic fever, emphasizing the need to approach infection protection with complementary efforts. In a randomized controlled design, we examined the applicability of patient‐performed daily spirometry [forced expiratory volume in one second (FEV1)] as an early warning tool and explored the effectiveness of positive expiratory pressure (PEP) in preventing pneumonia among 80 AML patients. Twenty‐five incidences of pneumonia were detected among 23 patients (6 interventions, 17 controls), giving a prevalence of 28.75% during 5420 days of observation. We found a significant difference in incidence between intervention versus control group (2.17 per 1000 days vs. 6.52 per 1000 days, P = 0.021, respectively). A cross point at 80‐76% of the personal FEV1 reference value showed high sensitivity and specificity on pneumonia development. Our data demonstrate the feasibility of educating AML patients in their continuous daily measurement of FEV1 and use of PEP. Daily measures of FEV1 may be an important early warning tool for assessment of pulmonary deterioration during critical phases of neutropenia. We suggest that strategic patient education in the use of spirometry and PEP should be part of standard of care for AML patients undergoing induction chemotherapy. Am. J. Hematol. 91:271–276, 2016. © 2015 The Authors. American Journal of Hematology Published by Wiley Periodicals, Inc.
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Affiliation(s)
- Tom Møller
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Claus Moser
- Department of Clinical MicrobiologyCopenhagen University HospitalRigshospitalet Denmark
| | - Lis Adamsen
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Grith Rugaard
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Mary Jarden
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Tina S. Bøtcher
- Department of HaematologyCopenhagen University Hospital Herlev, Copenhagen Denmark
| | - Liza Wiedenbein
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Lars Kjeldsen
- Department of HaematologyCopenhagen University HospitalRigshospitalet Denmark
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Yan CH, Xu T, Zheng XY, Sun J, Duan XL, Gu JL, Zhao CL, Zhu J, Wu YH, Wu DP, Hu JD, Huang H, Jiang M, Li J, Hou M, Wang C, Shao ZH, Liu T, Hu Y, Huang XJ. [Epidemiology of febrile neutropenia in patients with hematological disease-a prospective multicentre survey in China]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:177-82. [PMID: 27033752 PMCID: PMC7342950 DOI: 10.3760/cma.j.issn.0253-2727.2016.03.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To investigate the incidence, clinical and microbiological features of febrile, and risk factors during neutropenia periods in patients with hematological diseases. METHODS From October 20, 2014 to March 20, 2015, consecutive patients who had hematological diseases and developed neutropenia during hospitalization were enrolled in the prospective, multicenter and observational study. RESULTS A total of 784 episodes of febrile occurred in 1 139 neutropenic patients with hematological diseases. The cumulative incidence of febrile was 81.9% at 21 days after neutropenia. Multivariate analysis suggested that central venous catheterization (P<0.001, HR=3.407, 95% CI 2.276-4.496), gastrointestinal mucositis (P<0.001, HR=10.548, 95% CI 3.245-28.576), previous exposure to broad-spectrum antibiotics within 90 days (P<0.001, HR=3.582, 95% CI 2.387-5.770) and duration of neutropenia >7 days (P<0.001,HR=4.194, 95% CI 2.572-5.618) were correlated with higher incidence of febrile during neutropenia. With the increase of the risk factors, the incidence of febrile increased gradually (35.4%, 69.2%, 86.1%, 95.6%, P<0.001). Of 784 febrile cases, 253 (32.3%) were unknown origin, 429 (54.7% )of clinical documented infections and 102(13.0%) of microbiological documented infections. The most common sites of infection were pulmonary (49.5%), upper respiratory (16.0%), crissum (9.8%), blood stream (7.7%). The most common pathogens were gram-negative bacteria (44.54%), followed by gram-positive bacteria (37.99% ) and fungi (17.47% ). There was no significant difference in mortality rates between cases with febrile and cases without febrile (9.2% vs 4.8%, P=0.099). Multivariate analysis also suggested that >40 years old (P=0.047, HR=5.000, 95% CI 0.853-28.013), hemodynamic instability (P=0.001, HR=13.185, 95% CI 2.983-54.915), prior colonization or infection by resistant pathogens (P=0.005, HR=28.734, 95% CI 2.921-313.744), blood stream infection (P=0.038, HR=9.715, 95% CI 1.110-81.969) and pulmonary infection (P=0.031, HR=25.905, 95% CI 1.381-507.006) were correlated with higher mortality rate in cases with febrile. CONCLUSIONS Febrile was the common complication during neutropenia periods in patients with hematological disease. There was different distribution of organisms in different sites of infection. Moreove, the duration of neutropenia >7 days, central venous catheterization, gastrointestinal mucositis and previous exposure to broad-spectrum antibiotics within 90 days were the risk factors for the higher incidence of febrile.
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Affiliation(s)
- C H Yan
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
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A Quantitative Approach to Distinguish Pneumonia From Atelectasis Using Computed Tomography Attenuation. J Comput Assist Tomogr 2016; 40:746-51. [DOI: 10.1097/rct.0000000000000438] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kim DS, Kang KW, Yu ES, Kim HJ, Kim JS, Lee SR, Park Y, Sung HJ, Yoon SY, Choi CW, Kim BS. Selection of elderly acute myeloid leukemia patients for intensive chemotherapy: effectiveness of intensive chemotherapy and subgroup analysis. Acta Haematol 2014; 133:300-9. [PMID: 25470986 DOI: 10.1159/000362777] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 04/09/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND Despite the advances in acute myeloid leukemia (AML) treatment, the prognosis of elderly patients remains poor and no definitive treatment guideline has been established. In the present study, we aimed to evaluate the effectiveness of intensive chemotherapy in elderly AML patients and to determine which subgroup of patients would be most responsive to the therapy. METHODS We retrospectively analyzed 84 elderly patients: 35, 19, and 30 patients were administered intensive chemotherapy, low-dose chemotherapy, and supportive care, respectively. RESULTS Among those who received intensive chemotherapy, there were 17 cases of remission after induction chemotherapy; treatment-related mortality was 22.9%. The median overall survival was 7.9 months. Multivariate analysis indicated that the significant prognostic factors for overall survival were performance status, fever before treatment, platelet count, blast count, cytogenetic risk category, and intensive chemotherapy. Subgroup analysis showed that intensive chemotherapy was markedly effective in the relatively younger patients (65-70 years) and those with de novo AML, better-to-intermediate cytogenetic risk, no fever before treatment, high albumin levels, and high lactate dehydrogenase levels. CONCLUSIONS Elderly AML patients had better outcomes with intensive chemotherapy than with low-intensity chemotherapy. Thus, appropriate subgroup selection for intensive chemotherapy is likely to improve therapeutic outcome.
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Affiliation(s)
- Dae Sik Kim
- Division of Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, South Korea
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Penack O, Becker C, Buchheidt D, Christopeit M, Kiehl M, von Lilienfeld-Toal M, Hentrich M, Reinwald M, Salwender H, Schalk E, Schmidt-Hieber M, Weber T, Ostermann H. Management of sepsis in neutropenic patients: 2014 updated guidelines from the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO). Ann Hematol 2014; 93:1083-95. [PMID: 24777705 PMCID: PMC4050292 DOI: 10.1007/s00277-014-2086-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 04/09/2014] [Indexed: 12/29/2022]
Abstract
Sepsis is a major cause of mortality during the neutropenic phase after intensive cytotoxic therapies for malignancies. Improved management of sepsis during neutropenia may reduce the mortality of cancer therapies. Clinical guidelines on sepsis treatment have been published by others. However, optimal management may differ between neutropenic and non-neutropenic patients. Our aim is to give evidence-based recommendations for haematologist, oncologists and intensive care physicians on how to manage adult patients with neutropenia and sepsis.
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Affiliation(s)
- Olaf Penack
- Department of Hematology, Oncology and Tumourimmunology, Charité Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany,
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13
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Jeddi R, Achour M, Amor RB, Aissaoui L, Bouterâa W, Kacem K, Lakhal RB, Abid HB, BelHadjAli Z, Turki A, Meddeb B. Factors associated with severe sepsis: prospective study of 94 neutropenic febrile episodes. Hematology 2013; 15:28-32. [DOI: 10.1179/102453310x12583347009577] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Ramzi Jeddi
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Mériem Achour
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Ramzi Ben Amor
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Lamia Aissaoui
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Walid Bouterâa
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Karima Kacem
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Raihane Ben Lakhal
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Héla Ben Abid
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Zaher BelHadjAli
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Amel Turki
- Department of Microbiology and Biochemical AnalysisAziza Othmana University Hospital, Tunis, Tunisia
| | - Balkis Meddeb
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
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Lee YM, Lockwood C. Prognostic factors for risk stratification of adult cancer patients with chemotherapy-induced febrile neutropenia: a systematic review and meta-analysis. Int J Nurs Pract 2013; 19:557-76. [PMID: 24330206 DOI: 10.1111/ijn.12099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Chemotherapy-induced febrile neutropenia patients are heterogeneous in their risk of adverse outcomes. Management strategies are tailored according to level of risk. Many emerging predictors for risk stratification remain controversial being based on single studies only. A systematic review was conducted to determine the strength of association of all identified predictors. Studies were obtained from electronic databases, grey literatures and reference lists. Methodological quality of studies was assessed for internal validity and representativeness. Seven studies (four prospective and three retrospective cohorts) investigating 22 factors were reported. Fixed effects meta-analysis showed: hypotension and thrombocytopenia were significant predictors for high-risk. Additional predictors that might enhance performance of current models include: tachypnoea, presence of central venous catheter, duration and severity of neutropenia. Further research to investigate new factors/markers is needed to develop a robust prognostic model, which is the key to enhance patient safety.
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Affiliation(s)
- Yee Mei Lee
- Singapore National University Hospital Centre for Evidence Based Nursing, A Joanna Briggs Institute Collaborating Centre, Singapore; The School of Translational Health Science, Faculty of Health Sciences, University of Adelaide; National Cancer Institute, Singapore National University Hospital
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Abstract
Neutropenic fever sepsis syndromes are common among patients with cancer who are receiving intensive cytotoxic systemic therapy. Recognition of the syndromes and timely initial antibacterial therapy is critical for survival and treatment success. Outcomes are linked to myeloid reconstitution and recovery from neutropenia, control of active comorbidities, and appropriate treatment of the infections that underlie the sepsis syndrome. Hematologists and oncologists must be clear about the prognosis and treatment goals to work effectively with critical care physicians toward the best outcomes for patients with cancer who develop neutropenic sepsis syndromes.
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Affiliation(s)
- Eric J Bow
- Department of Medical Microbiology and Infectious Diseases, The University of Manitoba, Winnipeg, Manitoba R3T 2N2, Canada.
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16
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The Multinational Association for Supportive Care in Cancer (MASCC) risk index score: 10 years of use for identifying low-risk febrile neutropenic cancer patients. Support Care Cancer 2013; 21:1487-95. [PMID: 23443617 DOI: 10.1007/s00520-013-1758-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 02/11/2013] [Indexed: 01/20/2023]
Abstract
The Multinational Association for Supportive Care in Cancer risk index score developed, through a multinational collaboration, was published in 2000 with the aim to identify patients with chemotherapy-induced febrile neutropenia at low risk of serious medical complication development. It has been endorsed as a reliable tool since 2002 by Infectious Diseases Society of America. Ten years after, we thought worth to review its use, its characteristics in the external validations that occurred after the initial publication and also to review how the recognition of a group of patients at low risk has changed the management of febrile neutropenia. We also raise the issue of identification of high-risk patients that remains a challenge today.
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Lynn JJ, Chen KF, Weng YM, Chiu TF. Risk factors associated with complications in patients with chemotherapy-induced febrile neutropenia in emergency department. Hematol Oncol 2013; 31:189-96. [DOI: 10.1002/hon.2040] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 10/16/2012] [Accepted: 12/05/2012] [Indexed: 11/08/2022]
Affiliation(s)
- Jiun-Jen Lynn
- Department of Emergency Medicine, Chang Gung Memorial Hospital; Chang Gung University College of Medicine; Taoyuan Taiwan
| | - Kuan-Fu Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital; Chang Gung University College of Medicine; Taoyuan Taiwan
| | - Yi-Ming Weng
- Department of Emergency Medicine, Chang Gung Memorial Hospital; Chang Gung University College of Medicine; Taoyuan Taiwan
| | - Te-Fa Chiu
- Department of Emergency Medicine, Chang Gung Memorial Hospital; Chang Gung University College of Medicine; Taoyuan Taiwan
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18
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Lee YM, Lang D, Lockwood C. Prognostic factors for risk stratification of adult cancer patients with chemotherapy-induced febrile neutropenia: a systematic review and meta-analysis. ACTA ACUST UNITED AC 2012; 10:2593-2657. [PMID: 27820557 DOI: 10.11124/jbisrir-2012-31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Increasing numbers of studies identify new prognostic factors for categorising chemotherapy-induced febrile neutropenia adult cancer patients into high- or low-risk groups for adverse outcomes. These groupings are used to tailor therapy according to level of risk. However many emerging factors with prognostic significance remain controversial, being based on single studies only. OBJECTIVES A systematic review was conducted to determine the strength of association of all identified factors associated with the outcomes of chemotherapy-induced febrile neutropenia patients. INCLUSION CRITERIA The participants included were adults of 15 years old and above, with a cancer diagnosis and who underwent cancer treatment.The review focused on clinical factors and their association with the outcomes of cancer patients with chemotherapy-induced febrile neutropenia at presentation of fever.All quantitative studies published in English which investigated clinical factors for risk stratification of adult cancer patients with chemotherapy-induced febrile neutropenia were considered.The primary outcome of interest was to identify the clinical factors for risk stratification of adult cancer patients with chemotherapy-induced febrile neutropenia. SEARCH STRATEGY Electronic databases searched from their respective inception date up to December 2011 include MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Science-Direct, Scopus and Mednar. METHODOLOGICAL QUALITY The quality of the included studies was subjected to assessment by two independent reviewers. The standardised critical appraisal tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used to assess the following criteria: representativeness of study population; clearly defined prognostic factors and outcomes; whether potential confounders were addressed and appropriate statistical analysis was undertaken for the study design. DATA COLLECTION Data extraction was performed using a modified version of the standardised extraction tool from the JBI-MAStARI. Prognostic factors and the accompanying odds ratio reported for the significance of these factors that were identified by multivariate regression, were extracted from each included study. DATA SYNTHESIS Studies results were pooled in statistical meta-analysis using Review Manager 5.1. Where statistical pooling was not possible, the findings were presented in narrative form. RESULTS Seven studies (four prospective cohort and three retrospective cohort) investigating 22 factors in total were included. Fixed effects meta-analysis showed: hypotension [OR=1.66, 95%CI, 1.14-2.41, p=0.008] and thrombocytopenia [OR=3.92, 95%CI, 2.19-7.01, p<0.00001)] were associated with high-risk of adverse outcomes for febrile neutropenia. Other factors that were statistically significant from single studies included: age of patients, clinical presentation at fever onset, presence or absence of co-morbidities, infections, duration and severity of neutropenia state. Five prognostic factors failed to demonstrate an association between the variables and the outcomes measured and they include: presence of pneumonia, total febrile days, median days to fever, recovery from neutropenia and presence of moderate clinical symptoms in association with Gram-negative bacteraemia. CONCLUSIONS Despite the overall limitations identified in the included studies, this review has provided a synthesis of the best available evidence for the prognostic factors used in risk stratification of febrile neutropenia patients. However, the dynamic aspects of prognostic model development, validation and utilisation have not been addressed adequately thus far. Given the findings of this review, it is timely to address these issues and improve the utilisation of prognostic models in the management of febrile neutropenia patients. IMPLICATIONS FOR PRACTICE The identified factors are similar to the factors in current prognostic models. However, additional factors that were reported to be statistically significant in this review (thrombocytopenia, presence of central venous catheter, and duration and severity of neutropenia) have not previously been included in prognostic models. This review has found these factors may improve the performance of current models by adding or replacing some of the factors. IMPLICATIONS FOR RESEARCH The role of risk stratification of chemotherapy-induced febrile neutropenia patients continues to evolve as the practice of risk-based therapy has been demonstrated to be beneficial to patients, clinicians and health care organisations. Further research to identify new factors /markers is needed to develop a new model which is reliable and accurate for these patients, regardless of cancer types. A robust and well-validated prognostic model is the key to enhance patient safety in the risk-based management of cancer patients with chemotherapy-induced febrile neutropenia.
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Affiliation(s)
- Yee Mei Lee
- a Ms Nursing, Master of Clinical Science candidate 1. The Joanna Briggs Institute, Faculty of Health Sciences, University of Adelaide, Adelaide, SA 5005 2. Singapore National University Hospital Centre for Evidence Based Nursing, a collaborating centre of the Joanna Briggs Institute
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DNA repair gene XPD and XRCC1 polymorphisms and the risk of febrile neutropenia and mucositis in children with leukemia and lymphoma. Leuk Res 2011; 36:565-9. [PMID: 22047709 DOI: 10.1016/j.leukres.2011.10.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 08/26/2011] [Accepted: 10/09/2011] [Indexed: 11/22/2022]
Abstract
The aim of the study is to investigate association between DNA repair gene XPD and XRCC1 polymorphisms and febrile neutropenia (FN) and mucositis. The study population consisted of 29 children with Burkitt lymphoma and 61 children with acute lymphoblastic leukemia. Analysis revealed that XRCC1194Trp allele showed a protective effect against longer FN and mucositis. There was also statistically increased risk for severe mucositis in patients with XRCC1Arg399Gln polymorphism. There are no studies that have examined this relationship before. Further studies with larger cohorts are needed to clarify the association.
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Fortún J, Sanz MÁ, Madero L, López J, de la Torre J, Jarque I, Vallejo C. Update on bacteraemia in oncology and hematology. Enferm Infecc Microbiol Clin 2011; 29 Suppl 4:48-53. [DOI: 10.1016/s0213-005x(11)70036-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Mebis J, Goossens H, Berneman ZN. Antibiotic management of febrile neutropenia: current developments and future directions. J Chemother 2010; 22:5-12. [PMID: 20227985 DOI: 10.1179/joc.2010.22.1.5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Mortality due to febrile neutropenia has decreased since the concept of empiric therapy became standard care. However, infectious complications remain the most common adverse events of chemotherapy. bacterial epidemiology has changed during the past decades. There is currently an increasing trend in infections due to Gramnegative bacteria which have higher rates of resistance for a variety of reasons.The use of biomarkers for diagnosis remains a domain of further investigation. Since the patient population with febrile neutropenia is very heterogeneous, models of risk assessment have been developed with the most commonly used today being the mASCC score.Oral antibiotic treatment seems to be appropriate in low-risk patients. In moderate or high-risk patients monotherapy is the most common option. However, due to emerging resistance this could change by next year. Some new antibiotics have been developed, but experience in the treatment of neutropenic fever is limited. The use of antibiotics for prophylaxis remains controversial, although recent studies suggest a reduction in death from all causes.
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Affiliation(s)
- J Mebis
- Division of Hematology, Antwerp University Hospital, Edegem Belgium.
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22
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The suggestion of a risk stratification system for febrile neutropenia in patients with hematologic disease. Leuk Res 2010; 34:294-300. [DOI: 10.1016/j.leukres.2009.08.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2009] [Revised: 08/03/2009] [Accepted: 08/17/2009] [Indexed: 10/20/2022]
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Pierrakos C, Vincent JL. Sepsis biomarkers: a review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R15. [PMID: 20144219 PMCID: PMC2875530 DOI: 10.1186/cc8872] [Citation(s) in RCA: 845] [Impact Index Per Article: 60.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Revised: 12/28/2009] [Accepted: 02/09/2010] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Biomarkers can be useful for identifying or ruling out sepsis, identifying patients who may benefit from specific therapies or assessing the response to therapy. METHODS We used an electronic search of the PubMed database using the key words "sepsis" and "biomarker" to identify clinical and experimental studies which evaluated a biomarker in sepsis. RESULTS The search retrieved 3370 references covering 178 different biomarkers. CONCLUSIONS Many biomarkers have been evaluated for use in sepsis. Most of the biomarkers had been tested clinically, primarily as prognostic markers in sepsis; relatively few have been used for diagnosis. None has sufficient specificity or sensitivity to be routinely employed in clinical practice. PCT and CRP have been most widely used, but even these have limited ability to distinguish sepsis from other inflammatory conditions or to predict outcome.
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Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, route de Lennik 808, 1070 Brussels, Belgium.
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The predictive value of interleukin-8 (IL-8) in hospitalised patients with fever and chemotherapy-induced neutropenia. Eur J Cancer 2009; 45:596-600. [DOI: 10.1016/j.ejca.2008.10.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Revised: 10/27/2008] [Accepted: 10/29/2008] [Indexed: 11/22/2022]
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