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Xu Y, Gao H, Li H. The gut microbiome: an important factor influencing therapy for pediatric acute lymphoblastic leukemia. Ann Hematol 2024; 103:2621-2635. [PMID: 37775598 DOI: 10.1007/s00277-023-05480-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/24/2023] [Indexed: 10/01/2023]
Abstract
Acute lymphoblastic leukemia (ALL) is the most prevalent form of pediatric leukemia. The gut microbiome (GM) is crucial for proper nutrition, immunity, and biological conflict. Since the relationship between ALL and GM is bidirectional, ALL occurrence and treatment are closely related to GM destruction and the development of impaired immunity. Studies have discovered significant GM alterations in patients with ALL, including decreased diversity, that are likely directly caused by the development of ALL. Chemotherapy, antibiotic therapy, and hematopoietic stem cell transplantation (HSCT) are the mainstays of treatment for pediatric ALL. These approaches affect the composition, diversity, and abundance of intestinal microorganisms, which in turn affects therapeutic efficiency and can cause a variety of complications. Modulating the GM can aid the recovery of patients with ALL. This article discusses the various treatment modalities for pediatric ALL and their corresponding effects on the GM, as well as the changes in the GM that occur in children with ALL from diagnosis to treatment. Gaining a greater understanding of the link between ALL and the GM is expected to help improve treatment for pediatric ALL in the future.
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Affiliation(s)
- Yafang Xu
- Department of Microecology, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, China
| | - Hui Gao
- Department of Hematology and Oncology, Dalian Medical Center for Women and Children, Dalian, China
| | - Huajun Li
- Department of Microecology, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, China.
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Koo J, Hord J, Gilliam C, Rae ML, Staubach K, Nowacki K, Lyren A, Coffey M, Dandoy CE. Levofloxacin prophylaxis in pediatric oncology and hematopoietic stem cell transplantation: a literature review. Pediatr Hematol Oncol 2024:1-17. [PMID: 38975680 DOI: 10.1080/08880018.2024.2353888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/08/2023] [Indexed: 07/09/2024]
Abstract
Bloodstream infections (BSI) are one of the leading causes of morbidity and mortality in children and young adults receiving chemotherapy for malignancy or undergoing hematopoietic stem cell transplantation (HSCT). Antibiotic prophylaxis is commonly used to decrease the risk of BSI; however, antibiotics carry an inherent risk of complications. The aim of this manuscript is to review levofloxacin prophylaxis in pediatric oncology patients and HSCT recipients. We reviewed published literature on levofloxacin prophylaxis to prevent BSI in pediatric oncology patients and HSCT recipients. Nine manuscripts were identified. The use of levofloxacin is indicated in neutropenic children and young adults receiving intensive chemotherapy for leukemia or undergoing HSCT. These results support the efficacy of levofloxacin in pediatric patients with leukemia receiving intensive chemotherapy and should be considered in pediatric patients undergoing HSCT prior to engraftment.
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Affiliation(s)
- Jane Koo
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jeffrey Hord
- Showers Family Center for Childhood Cancer and Blood Disorders, Akron Children's Hospital, Akron, OH, USA
| | - Craig Gilliam
- Department of Infection Prevention and Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Mary Lynn Rae
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Katherine Staubach
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Katherine Nowacki
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Anne Lyren
- Case Western Reserve University Cleveland, University Hospital Rainbow Babies & Children's Hospital Cleveland, Cleveland, OH, USA
| | | | - Christopher E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Medical Center, Cincinnati, OH, USA
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Penkert RR, Jones BG, Tang L, Su Y, Jeha S, Yang J, Yang W, Ferrolino J, Strength R, Pui CH, Cross SJ, Hurwitz JL, Wolf J. Association of Vitamin A and D Deficiencies with Infectious Outcomes in Children Undergoing Intensive Induction Therapy for Acute Lymphoblastic Leukemia. J Pediatr 2024; 273:114148. [PMID: 38880379 DOI: 10.1016/j.jpeds.2024.114148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/21/2024] [Accepted: 06/11/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE To evaluate the association between deficiency of vitamin A or D at diagnosis of pediatric acute lymphoblastic leukemia (ALL) and subsequent infectious complications during induction therapy. STUDY DESIGN We conducted an institutional review board-approved, retrospective cohort study of children with newly diagnosed ALL from 2007 to 2017 at St. Jude Children's Research Hospital. We measured vitamin D, vitamin D binding protein, retinol binding protein as a surrogate for vitamin A, and immunoglobulin isotypes in serum obtained at ALL diagnosis, and we assessed the association between vitamin deficiencies or levels and infection-related complications during the 6-week induction phase using Cox regression models. RESULTS Among 378 evaluable participants, vitamin A and D deficiencies were common (43% and 17%, respectively). Vitamin D deficiency was associated with higher risks of febrile neutropenia (adjusted hazard ratio [aHR], 1.7; P = .0072), clinically documented infection (aHR, 1.73; P = .025), and likely bacterial infection (aHR, 1.86; P = .008). Conversely, vitamin A deficiency was associated solely with a lower risk of sepsis (aHR, 0.19; P = .027). CONCLUSIONS In this retrospective study, vitamin D deficiency was associated with an increased risk of common infection-related complications during induction therapy for ALL. Additional studies are warranted to evaluate whether vitamin D supplementation could mitigate this effect.
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Affiliation(s)
- Rhiannon R Penkert
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Bart G Jones
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Li Tang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Yin Su
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Sima Jeha
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN; Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Jun Yang
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Wenjian Yang
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Jose Ferrolino
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Rachel Strength
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Shane J Cross
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Julia L Hurwitz
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN.
| | - Joshua Wolf
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN; Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN.
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Davis AL, Stevens AM, Brackett J, Marquez L, Foster CE, Clemente AS, Sauer HE, Stimes GT, Campbell JR. Levofloxacin prophylaxis for pediatric leukemia patients: monitoring of outcomes for sustained benefit and consequences. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e90. [PMID: 38807931 PMCID: PMC11131004 DOI: 10.1017/ash.2024.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/16/2024] [Accepted: 04/16/2024] [Indexed: 05/30/2024]
Abstract
Levofloxacin prophylaxis reduces bloodstream infections in neutropenic patients with acute myeloid leukemia or relapsed acute lymphoblastic leukemia. A retrospective, longitudinal cohort study compares incidence of bacteremia, multidrug-resistant organisms (MDRO), and Clostridioides difficile (CDI) between time periods of levofloxacin prophylaxis implementation. Benefits were sustained without increasing MDRO or CDI.
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Affiliation(s)
- Andrea L. Davis
- Department Infection Control and Prevention, Texas Children’s Hospital, Houston, TX, USA
| | - Alexandra M. Stevens
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Cancer Center, Texas Children’s Hospital, Houston, TX, USA
| | - Julienne Brackett
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Cancer Center, Texas Children’s Hospital, Houston, TX, USA
| | - Lucila Marquez
- Department Infection Control and Prevention, Texas Children’s Hospital, Houston, TX, USA
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
| | - Catherine E. Foster
- Department Infection Control and Prevention, Texas Children’s Hospital, Houston, TX, USA
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
| | - Adriana Sarmiento Clemente
- Department of Pediatrics, Division of Infectious Diseases, Arkansas Children’s Hospital, Little Rock, AR, USA
| | - Hannah E. Sauer
- Department of Global Pediatric Medicine, St. Jude Medical Center, Memphis, TN, USA
| | - Grant T. Stimes
- Department of Pharmacy, Texas Children’s Hospital, Houston, TX, USA
| | - Judith R. Campbell
- Department Infection Control and Prevention, Texas Children’s Hospital, Houston, TX, USA
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
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Junqi Z, Jie C, Jinglin W, Jinmiao L, Guoping L, Yi W, Zhiping L. A retrospective study of the efficacy and safety of levofloxacin in children with severe infection. Front Pediatr 2024; 12:1381742. [PMID: 38646513 PMCID: PMC11026612 DOI: 10.3389/fped.2024.1381742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/18/2024] [Indexed: 04/23/2024] Open
Abstract
Objectives Levofloxacin is widely used because of its broad-spectrum antimicrobial activity and convenient dosing schedule. However, the relevance of its use in children remains to be investigated. The purpose of this study is to investigate the efficacy and safety of levofloxacin use in children with severe infections. Methods We conducted a retrospective observational study of patients <18 years of age who received levofloxacin intravenously in the Pediatric Intensive Care Unit (PICU) of our hospital during the period between 2021 and 2022. Patient demographics, course characteristics, clinical effectiveness, and adverse event correlations were extracted through a retrospective tabular review. Results We included 25 patients treated with 28 courses of levofloxacin. The mean age of these children treated with levofloxacin was 4.41 years. Conversion of pathogenic microbiological test results to negative after levofloxacin treatment was detected in 11 courses (39.29%). A decrease in inflammatory markers, white blood cell or C-reactive protein counts, was detected in 18 courses (64.29%). A total of 57 adverse events occurred during the treatment period, of which 21 were possibly related to levofloxacin and no adverse events were probably related to levofloxacin. Conclusion The effectiveness of levofloxacin use in children with serious infections is promising, especially for the treatment of multidrug-resistant bacteria. Adverse events occurring during the initiation of levofloxacin therapy in children are reported to be relatively common, but in this study, only a small percentage of them were possibly related to levofloxacin, and none of them were highly possibly related to levofloxacin.
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Affiliation(s)
- Zhang Junqi
- Department of Clinical Pharmacy, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Cai Jie
- Department of Clinical Pharmacy, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Wang Jinglin
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lu Jinmiao
- Department of Clinical Pharmacy, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Lu Guoping
- Pediatric Intensive Care Unit, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Wang Yi
- Department of Neurology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Li Zhiping
- Department of Clinical Pharmacy, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
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Goggin KP, Lu L, Lee DE, Howell CR, Srivastava D, Brinkman TM, Armstrong GT, Bhakta N, Robison LL, Ehrhardt MJ, Hudson MM, Krull KR, Pui CH, Rubnitz J, Ness KK, Wolf J. Severe Sepsis During Treatment for Childhood Leukemia and Sequelae Among Adult Survivors. JAMA Netw Open 2024; 7:e242727. [PMID: 38497960 PMCID: PMC10949094 DOI: 10.1001/jamanetworkopen.2024.2727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/24/2024] [Indexed: 03/19/2024] Open
Abstract
Importance Children undergoing treatment for leukemia are at increased risk of severe sepsis, a dysregulated immune response to infection leading to acute organ dysfunction. As cancer survivors, they face a high burden of long-term adverse effects. The association between sepsis during anticancer therapy and long-term organ dysfunction in adult survivors of childhood cancer has not been examined. Objective To determine whether severe sepsis during therapy for leukemia in childhood is associated with subsequent chronic health conditions in adult survivors. Design, Setting, and Participants This cohort study included 644 adult survivors of childhood leukemia who were diagnosed between January 1, 1985, and July 19, 2010, and participated in the St Jude Lifetime Cohort Study. Participants were excluded if they received hematopoietic cell transplant or had relapsed leukemia. Data collection ended June 30, 2017. Data were analyzed from July 1, 2020, to January 5, 2024. Exposures Severe sepsis episodes, defined according to consensus criteria as septic shock, acute respiratory distress syndrome, or multiorgan dysfunction associated with infection occurring during anticancer therapy, were abstracted by medical record review for all participants. Main Outcomes and Measures Common Terminology Criteria for Adverse Events-defined chronic health condition outcomes were independently abstracted. Associations between sepsis and cumulative incidence of chronic health conditions (eg, cardiovascular, pulmonary, kidney, neurological, and neurocognitive outcomes) were compared by adjusted hazard ratios from Cox proportional hazards logistic regression. Inverse propensity score weighting was used to adjust for potential confounders, including age, year of diagnosis, and leukemia type. Results The study sample consisted of 644 adult survivors of pediatric leukemia (329 women [51.1%] and 315 men [48.9%]; including 56 with a history of acute myeloid leukemia and 585 with a history of acute lymphoblastic leukemia) who were most recently evaluated at a median age of 24.7 (IQR, 21.2-28.3) years at a median time after leukemia diagnosis of 17.3 (IQR, 13.7-21.9) years. Severe sepsis during treatment of acute childhood leukemia occurred in 46 participants (7.1%). Participants who experienced severe sepsis during treatment were more likely to develop moderate to severe neurocognitive impairment (29 of 46 [63.0%] vs 310 of 598 [51.8%]; adjusted hazard ratio, 1.86 [95% CI, 1.61-2.16]; P < .001) significantly affecting attention, executive function, memory and visuospatial domains. Sepsis was not associated with long-term risk of cardiovascular, pulmonary, kidney, or neurological chronic health conditions. Conclusions and Relevance In this cohort study of long-term outcomes in survivors of pediatric leukemia, severe sepsis during anticancer therapy for leukemia was associated with a selectively increased risk for development of serious neurocognitive sequelae. Efforts to reduce the effects of anticancer therapy on long-term function and quality of life in survivors might include prevention of severe sepsis during therapy and early detection or amelioration of neurocognitive deficits in survivors of sepsis.
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Affiliation(s)
- Kathryn P. Goggin
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
- Now with Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Lu Lu
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Danielle E. Lee
- Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children’s Hospital, Memphis
| | - Carrie R. Howell
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Deokumar Srivastava
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Tara M. Brinkman
- Department of Psychology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Nickhill Bhakta
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Mathew J. Ehrhardt
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kevin R. Krull
- Department of Psychology, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Ching-Hon Pui
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Jeffrey Rubnitz
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Joshua Wolf
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children’s Hospital, Memphis
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Shi L, Huang S, Liu W. Infection prevention in induction chemotherapy for childhood acute leukaemia. J Hosp Infect 2024; 145:226-227. [PMID: 38103693 DOI: 10.1016/j.jhin.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/28/2023] [Accepted: 11/06/2023] [Indexed: 12/19/2023]
Affiliation(s)
- L Shi
- Key Laboratory of Paediatric Haematology, Children's Hospital Affiliated to Zhengzhou University/Henan Children's Hospital, Zhengzhou, People's Republic of China.
| | - S Huang
- Department of Hematology and Oncology, Children's Hospital Affiliated to Zhengzhou University/Henan Children's Hospital, Zhengzhou, People's Republic of China
| | - W Liu
- Department of Hematology and Oncology, Children's Hospital Affiliated to Zhengzhou University/Henan Children's Hospital, Zhengzhou, People's Republic of China
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Baltas I, Kavallieros K, Konstantinou G, Koutoumanou E, Gibani MM, Gilchrist M, Davies F, Pavlu J. The effect of ciprofloxacin prophylaxis during haematopoietic cell transplantation on infection episodes, exposure to treatment antimicrobials and antimicrobial resistance: a single-centre retrospective cohort study. JAC Antimicrob Resist 2024; 6:dlae010. [PMID: 38304723 PMCID: PMC10833646 DOI: 10.1093/jacamr/dlae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/08/2024] [Indexed: 02/03/2024] Open
Abstract
Objectives Fluroquinolone prophylaxis during haematopoietic cell transplantation (HCT) remains contentious. We aimed to determine its effectiveness and association with exposure to treatment antimicrobials and antimicrobial resistance. Methods All admission episodes for HCT (N = 400 , 372 unique patients) in a tertiary centre between January 2020 and December 2022 were studied. Allogeneic HCT (allo-HCT) recipients received prophylaxis with ciprofloxacin during chemotherapy-induced neutropenia, while autologous HCT (auto-HCT) recipients did not. Results Allo-HCT was performed for 43.3% (173/400) of patients, auto-HCT for 56.7% (227/400). Allo-HCT was associated with an average of 1.01 fewer infection episodes per 100 admission days (95% CI 0.62-1.40, P < 0.001) compared with auto-HCT. In allo-HCT, the total exposure to all antimicrobials was higher [+24.8 days of therapy (DOT)/100 admission days, P < 0.001], as was exposure to ciprofloxacin (+40.5 DOT/100 admission days, P < 0.001). By contrast, exposure to meropenem (-4.5 DOT/100 admission days, P = 0.02), piperacillin/tazobactam (-5.2 DOT/100 admission days, P < 0.001), aminoglycosides (-4.5 DOT/100 admission days, P < 0.001) and glycopeptides (-6.4 DOT/100 admission days, P < 0.001) was reduced. Enterobacteriaceae isolated during allo-HCT were more resistant to ciprofloxacin (65.5%, 19/29 versus 6.1%, 2/33, P < 0001), ceftriaxone (65.5%, 19/29 versus 9.1%, 3/33, P < 0.001), other antimicrobial classes. Vancomycin-resistant enterococci were more common in allo-HCT recipients (11%, 19/173 versus 0.9%, 2/227, P < 0.001). Inpatient mortality during allo- and auto-HCT was 9.8% (17/173) and 0.4% (1/227). respectively (P < 0.001). Conclusions Ciprofloxacin prophylaxis in allo-HCT was associated with fewer infection episodes and reduced exposure to treatment antimicrobials. Mortality in auto-HCT remained low. A significant burden of antimicrobial resistance was detected in allo-HCT recipients.
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Affiliation(s)
- Ioannis Baltas
- Department of Infection, Immunity and Inflammation, Institute of Child Health, University College London, London, UK
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Eirini Koutoumanou
- Population, Policy & Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Malick M Gibani
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Mark Gilchrist
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Frances Davies
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Jiri Pavlu
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Faculty of Medicine, Imperial College London, London, UK
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Singh N, Thursky K, Maron G, Wolf J. Fluoroquinolone prophylaxis in patients with neutropenia at high risk of serious infections: Exploring pros and cons. Transpl Infect Dis 2023; 25 Suppl 1:e14152. [PMID: 37746769 DOI: 10.1111/tid.14152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/30/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND The use of fluoroquinolones to prevent infections in neutropenic patients with cancer or undergoing hematopoietic stem cell transplantation (HSCT) is a controversial issue, with international guidelines providing conflicting recommendations. Although potential benefits are clear, concerns revolve around efficacy, potential harms, and antimicrobial resistance (AMR) implications. DISCUSSION Fluoroquinolone prophylaxis reduces neutropenic fever (NF) bloodstream infections and other serious bacterial infections, based on evidence from systematic reviews, randomized controlled trials, and observational studies in adults and children. Fluoroquinolone prophylaxis may also reduce infection-related morbidity and healthcare costs; however, evidence is conflicting. Adverse effects of fluoroquinolones are well recognized in the general population; however, studies in the cancer cohort where it is used for a defined period of neutropenia have not reflected this. The largest concern for routine use of fluoroquinolone prophylaxis remains AMR, as many, but not all, observational studies have found that fluoroquinolone prophylaxis might increase the risk of AMR, and some studies have suggested negative impacts on patient outcomes as a result. CONCLUSIONS The debate surrounding fluoroquinolone prophylaxis calls for individualized risk assessment based on patient characteristics and local AMR patterns, and prophylaxis should be restricted to patients at the highest risk of serious infection during the highest risk periods to ensure that the risk-benefit analysis is in favor of individual and community benefit. More research is needed to address important unanswered questions about fluoroquinolone prophylaxis in neutropenic patients with cancer or receiving HSCT.
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Affiliation(s)
- Nikhil Singh
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Pharmacy, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Karin Thursky
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Melbourne, Australia
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Joshua Wolf
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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Nair A, Elballushi R, Joshi R, Anjanappa S, Akter M, Arif S, Rehman S. Assessment of the Prevalence of Infections in Pediatric Patients With Acute Lymphoblastic Leukemia. Cureus 2023; 15:e46837. [PMID: 37954717 PMCID: PMC10636770 DOI: 10.7759/cureus.46837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
Infections cause notable treatment-related morbidity during pediatric acute lymphoblastic leukemia/lymphoma (ALL/LLy) therapy. Infections are the most critical cause of morbidity and mortality in children undergoing treatment for acute lymphoblastic leukemia (ALL). Children with ALL, who are frequently underweight, are at increased risk of community-acquired pathogens, nosocomial multidrug-resistant pathogens, and opportunistic microorganisms. A weakened immune system from ALL itself and chemotherapy's side effects further worsen the prognosis. PubMed and Google Scholar articles were curated in a Google document with shared access. Discussion and development of the paper were achieved over Zoom meetings. This narrative review aims to analyze and summarize various pathogens responsible for infections in children receiving treatment for ALL and their treatment regimen and prophylaxis. The incidence of viral infection is higher in ALL patients, followed by bacterial and fungal infections. Prevention via prophylaxis and timely initiation of treatment is essential for positive outcomes.
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Affiliation(s)
- Arun Nair
- Pediatrics, Saint Peter's University Hospital, New Brunswick, USA
| | - Ruaa Elballushi
- School of Medicine, Royal College of Surgeons in Ireland - Medical University of Bahrain, Busaiteen, BHR
| | - Riecha Joshi
- Pediatrics, Government Medical College, Kota, IND
| | - Sanvithi Anjanappa
- School of Medicine, Kempegowda Institute of Medical Sciences, Bangalore, IND
| | - Maksuda Akter
- School of Medicine, American International Medical University, Gros Islet, LCA
| | - Sehrish Arif
- Medicine, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore, PAK
| | - Sana Rehman
- Medicine, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore, PAK
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Dufrayer MC, Monteiro YMC, Carlesse FADMC, Motta F, Daudt LE, Michalowski MB. Antibiotic prophylaxis in acute childhood leukemia: What is known so far? Hematol Transfus Cell Ther 2023; 45:473-482. [PMID: 36522273 PMCID: PMC10627853 DOI: 10.1016/j.htct.2022.09.1279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/25/2022] [Accepted: 09/13/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The treatment of acute lymphoblastic leukemia (ALL) has evolved in recent decades, reaching an overall survival rate close to 90%. Currently, approximately 4% of patients with ALL die from secondary complications of chemotherapy. Among these complications, the most frequent is febrile neutropenia (FN). The treatment of acute myeloid leukemias (AMLs) is even more aggressive, being consequently related to a considerable amount of treatment-related toxicity with a high risk of severe infection and death. METHOD In order to reduce the infection-related risks in these groups of patients, systemic antibacterial prophylaxis has emerged as a possible approach. RESULTS Antibiotic prophylaxis during neutropenia periods in those undergoing chemotherapy have .already been proven in adults with acute leukemias (ALs). Among the possible available therapeutic options for bacterial prophylaxis in children with cancer, fluoroquinolones emerged with the most amount of evidence. Within this class, levofloxacin became the best choice. CONCLUSION Therefore, the use of levofloxacin seems to be indicated in very specific situations: in children who are known to be neutropenic for a long time, secondary to intensive chemotherapy; in children with AL undergoing chemotherapy to induce remission; or in children undergoing hematopoietic stem cell transplantation (HSCT). This article aims to describe recent evidence focusing on antibiotic prophylaxis in children with ALs.
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Affiliation(s)
- Mauro Cesar Dufrayer
- Santa Casa de Misericórdia de Porto Alegre, Hospital da Criança Santo Antônio, Av. Independência, 155, São João, CEP: 90240-510, Porto Alegre, RS, Brazil.
| | | | | | - Fabrizio Motta
- Santa Casa de Misericórdia de Porto Alegre, Hospital da Criança Santo Antônio, Av. Independência, 155, São João, CEP: 90240-510, Porto Alegre, RS, Brazil
| | - Liane Esteves Daudt
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Mariana Bohns Michalowski
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
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Escobedo-Melendez G, Paniagua-Padilla J, Caniza MA. Outcomes of Care-bundle Implementation for Children With Cancer and Suspected Bloodstream Infection in a Pediatric Oncology Unit in a Resource-limited Setting. J Pediatr Hematol Oncol 2023; 45:e798-e809. [PMID: 37526415 PMCID: PMC10521769 DOI: 10.1097/mph.0000000000002719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 06/20/2023] [Indexed: 08/02/2023]
Abstract
Bloodstream infections (BSIs) are a major cause of mortality among pediatric oncology patients in resource-limited settings. Effective, innovative strategies are needed to improve care and survival. In a pediatric oncology unit in Mexico, we retrospectively analyzed the risk factors for mortality related to BSI and the results of using a care-bundle intervention. The care-bundle consisted of a swift clinical evaluation, initial fluid-resuscitation support, obtaining blood cultures, and administration of effective empirical antibiotic therapy for suspected BSI. The outcomes of patients who received the care-bundle during a 12-month period were compared with those of patients treated with standard care during the 12 months preceding its implementation. The primary outcomes were BSI diagnosis, choice of antibiotics, and mortality. Of the 261 suspected BSIs treated with standard care, 33 (12.6%) infections were confirmed, and of the 308 treated with the care-bundle, 67 (21.7%) BSIs were confirmed. Thus, after implementation of the care-bundle, significantly more BSIs were diagnosed ( P =0.004), and BSI-related mortality was significantly reduced by 22.2% ( P = 0.035). Surgical resection and mechanical ventilation support were independently associated with BSI-related mortality, and receiving effective initial empirical antibiotic therapy was protective against mortality (odds ratio, 0.013; 95% CI: 0.002-0.105; P =0.001), which comprising cefepime plus amikacin or meropenem in 44 (80.0%) of the cases alive. Consistent use of a care-bundle with initial fluid resuscitation, obtaining a blood culture, and administering effective antibiotics to children with cancer and suspected BSI can decrease mortality.
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Affiliation(s)
- Griselda Escobedo-Melendez
- Institute for Research in Childhood and Adolescence Cancer, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Jenny Paniagua-Padilla
- Institute for Research in Childhood and Adolescence Cancer, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Miguela A. Caniza
- Departments of Global Pediatric Medicine and Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN
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Yin T, Han J, Hao J, Yu H, Qiu Y, Xu J, Peng Y, Wu X, Jin R, Zhou F. Clinical characteristics and risk factors of acute lymphoblastic leukemia in children with severe infection during maintenance treatment. Cancer Med 2023; 12:19372-19382. [PMID: 37768027 PMCID: PMC10587982 DOI: 10.1002/cam4.6495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Infection is the most common adverse event of acute lymphoblastic leukemia (ALL) treatment and is also one of the main causes of death. METHODS To investigate the clinical characteristics and risk factors of severe infections during the maintenance phase of ALL treatment, we conducted a retrospective study. RESULTS A total of 181 children were eligible and 46 patients (25.4%) suffered from 51 events of severe infection, most of which occurred in the first half year of the maintenance phase (52.9%). The most common infection was pulmonary infection (86.3%) followed by bloodstream infection (19.6%). The main symptoms of ALL patients with pulmonary infection were fever, cough, and shortness of breath. The main manifestations of computer tomography (CT) were ground glass shadow (56.8%), consolidation shadow (27.3%), and streak shadow (25%). Multivariate binary logistic regression analysis showed that agranulocytosis, agranulocytosis ≥7 days, anemia, and low globulin level were independent risk factors for severe infection during the maintenance phase (all p < 0.05). CONCLUSIONS Taken together, blood routine examinations and protein levels should be monitored regularly for ALL patients in the maintenance phase, especially in the first 6 months. For ALL patients with risk factors, preventive anti-infective or supportive therapies can be given as appropriate to reduce the occurrence of severe infections.
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Affiliation(s)
- Tiantian Yin
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Juan Han
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Jinjin Hao
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Hui Yu
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yining Qiu
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Jiawei Xu
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yun Peng
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Xiaoyan Wu
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Runming Jin
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Fen Zhou
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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Ejaz A, Belgaumi AF, Alam SE, Ashraf MS, Raza MR. Effectiveness of levofloxacin in the induction of chemotherapy in high-risk acute lymphoblastic leukaemia in children in a developing country. Ecancermedicalscience 2023; 17:1606. [PMID: 37799940 PMCID: PMC10550328 DOI: 10.3332/ecancer.2023.1606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Indexed: 10/07/2023] Open
Abstract
Background Infections significantly predominate during induction chemotherapy for acute lymphoblastic leukaemia (ALL) in children. Antibacterial prophylaxis is one strategy that lowers the risk of these infections. This study evaluates the role of levofloxacin prophylaxis on the frequency of infections, febrile neutropenia (FN) and outcomes associated with it along with the development of drug-resistance. Subject and methods This was a single-centre cohort study in which the data were collected from electronic health records between two cohorts of high-risk ALL patients in the induction phase: the first one before the initiation of levofloxacin prophylaxis and the second was after the implementation of levofloxacin prophylaxis. The variables were compared between both the groups and odds ratios were calculated for clinical outcomes. Results Out of 227 patients, 115 were given levofloxacin prophylaxis and 112 were in the no prophylaxis group. Both cohorts were similar in demographic factors, treatment regimen and supportive care services. There was a significant difference in total in-patient admissions along with FN admissions (p = 0.026). Microbiologically documented infections and infection-related critical interventions were significantly higher in the no prophylaxis group (p < 0.05). Odds ratios with a 95% confidence interval were applied to both groups for clinical outcomes in patients with and without FN which also illustrated similar results. Overall mortality and drug resistance patterns were similar among both groups. Conclusion This study emphasised that levofloxacin is effective in reducing inpatient admissions with FN and its complications but did not affect the drug-resistance pattern. Long-term monitoring for antibiotic resistance is mandatory.
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Affiliation(s)
- Areeba Ejaz
- Indus Hospital and Health Network, Plot C-76, Sector 31/5, Opposite Darussalam Society, Korangi Crossing, Karachi, Pakistan
| | | | - Syed Ejaz Alam
- Pakistan Medical and Research Council, PMRC Center for Hepatology and Gastroenterology, JPMC, Rafiqi H J Rd, Cantonment Karachi, 75510, Karachi City, Sindh, Pakistan
| | - Mohammad Shamvil Ashraf
- Indus Hospital and Health Network, Plot C-76, Sector 31/5, Opposite Darussalam Society, Korangi Crossing, Karachi, Pakistan
| | - Mohammad Rafie Raza
- Indus Hospital and Health Network, Plot C-76, Sector 31/5, Opposite Darussalam Society, Korangi Crossing, Karachi, Pakistan
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Almatrafi MA, Dassner AM, Aquino V, Slone T, Sebert M. Retrospective Observational Assessment of the Impact of Cefepime Prophylaxis in Neutropenic Pediatric Patients With Acute Myelogenous Leukemia. J Pediatric Infect Dis Soc 2023; 12:471-476. [PMID: 37591306 DOI: 10.1093/jpids/piad056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 08/14/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND The potential for cefepime prophylaxis to reduce bloodstream infections (BSIs) in pediatric patients with acute myelogenous leukemia (AML) has been incompletely characterized. METHODS A retrospective quasi-experimental study of patients under 21 years of age admitted with AML from 2010 through 2018 at two affiliated pediatric tertiary-care hospitals before and after the adoption of routine cefepime prophylaxis for afebrile AML patients during profound neutropenia. RESULTS The rate of BSIs per 1000 neutropenia days was significantly lower in the prophylaxis group than the baseline group (2.6 vs 15.5, incidence rate ratio [IRR] 0.17, 95% CI 0.09-0.32). Interrupted time-series analysis showed that a sharp reduction in BSIs coincided with the implementation of prophylaxis. Bacteremia with viridans group streptococci was frequent in the baseline group but not observed after adopting prophylaxis. Despite the increased use of cefepime, the rate of cefepime-nonsusceptible BSIs per 1000 neutropenia days decreased (1.6 vs 4.1, IRR 0.40, 95% CI 0.16-0.99). The median number of febrile neutropenia episodes per patient also decreased in the prophylaxis group, as did the proportion of patients admitted to the intensive care unit (ICU) (22/51 (43.1%) vs 26/38 (68.4%); risk difference -25.3%, 95% CI -44.4 to -2.8). A trend was observed toward an increased proportion of patients with Clostridioides difficile infection in the prophylaxis group (10/51 (19.6%) vs 3/38 (7.9%); risk difference 11.7%, 95% CI -3.4 to 29.0). CONCLUSIONS Cefepime prophylaxis was associated with a significant reduction in BSIs, febrile neutropenia, and ICU admission among pediatric AML patients.
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Affiliation(s)
| | - Aimee M Dassner
- Department of Pharmacy, Children's Health System of Texas, Dallas, Texas, USA
- Department of Pharmacy, Children's National Hospital, Washington, District of Columbia, USA
| | - Victor Aquino
- Division of Hematology and Oncology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tamra Slone
- Division of Hematology and Oncology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Michael Sebert
- Division of Infectious Diseases, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Parzen-Johnson S, Sun S, Scardina T, Patel SJ. Fluoroquinolone Use Among Hospitalized Children: Diagnosis-Based Stratification to Identify Stewardship Targets. Open Forum Infect Dis 2023; 10:ofad297. [PMID: 37323425 PMCID: PMC10264067 DOI: 10.1093/ofid/ofad297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/26/2023] [Indexed: 06/17/2023] Open
Abstract
Background As FQ (fluoroquinolone) use has shifted in pediatric populations, better metrics are needed to guide targeted antibiotic stewardship interventions and limit development of adverse events and resistance, particularly in medically complex children. In this study, we identify high-utilization groups based on underlying medical conditions and describe their relative FQ use over time. Methods This study is a retrospective analysis of data from the Pediatric Health Information System database from 2016 to 2020. We identify high-utilization groups based on underlying medical conditions using International Classification of Diseases, Ninth or Tenth Revision codes. We delineate overall trends in the use of FQs in the inpatient setting, including rate and proportional use by each patient group. Results Patients with an oncology diagnosis represent a large (25%-44%) and rising proportion (+4.8%/year, P = .001) of national FQ use over the study period. Patients with intra-abdominal infections, including appendicitis, have had a significant increase in both their relative proportional use of FQs (+0.6%/year, P = .037) and proportion of FQ use per admission encounter over the study period (+0.6%/year, P = .008). Patients with cystic fibrosis represent a decreasing proportion of overall use (-2.1%/year, P = .011) and have decreasing FQ use per inpatient encounter (-0.8%/year, P = .001). Conclusions Patients with an oncology diagnosis and patients with an intra-abdominal infection appear to be targets for FQ stewardship. Patients with cystic fibrosis have decreasing inpatient FQ use. Key Points: This study describes fluoroquinolone use among hospitalized children from 2016 to 2020, stratified by underlying diagnoses. These trends are used to identify high-yield antibiotic stewardship targets.
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Affiliation(s)
- Simon Parzen-Johnson
- Correspondence: Simon Parzen-Johnson, MD, Division of Infectious Diseases, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611 ()
| | - Shan Sun
- Division of Infectious Diseases, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Tonya Scardina
- Department of Pharmacy, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Yang M, Lu X, Xin L, Luo J, Diao S, Jia Z, Cheng G, Zeng L, Zhang L. Comparative effectiveness and safety of antibiotic prophylaxis during induction chemotherapy in children with acute leukaemia: a systematic review and meta-analysis. J Hosp Infect 2023; 136:20-29. [PMID: 36921630 DOI: 10.1016/j.jhin.2023.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/20/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Bacterial infections are common during induction therapy in children and adolescents with acute leukaemia and may cause infection-related mortality. AIM To determine the efficacy and safety of prophylactic antibiotics in paediatric patients with acute leukaemia receiving induction chemotherapy. METHODS From three English databases and four Chinese databases, we searched for randomized controlled trials (RCTs) and cohort studies that compared prophylactic antibiotics to placebo, no prophylaxis, or that compared one antibiotic versus another in paediatric patients with acute leukaemia undergoing induction chemotherapy. Two reviewers independently screened the studies, extracted data, and assessed the risk of bias using Cochrane Risk of Bias 2 tool and Newcastle-Ottawa Scale, and the certainty of evidence using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). FINDINGS Two RCTs and ten cohort studies were finally included. For children with acute lymphoblastic leukaemia, antibiotic prophylaxis, including levofloxacin, sulfamethoxazole-trimethoprim, or other antibiotics, probably reduced bacteraemia (risk ratio (RR): 0.44; 95% confidence interval (CI): 0.33-0.60; moderate certainty) without significantly increasing Clostridioides difficile infection (CDI) or invasive fungal infection. Levofloxacin reduced the CDI rate (RR: 0.08; 95% CI: 0.01-0.62; high certainty). Ciprofloxacin prophylaxis probably reduced infection-related mortality (RR: 0.12; 95% CI: 0.01-0.97; moderate certainty). In children with acute myeloid leukaemia, ciprofloxacin plus vancomycin may reduce febrile neutropenia (RR: 0.79; 95% CI: 0.66-0.94; low certainty). Individual studies indicated that prophylaxis increased antibiotic exposure but reduced non-preventive antibiotic exposure. CONCLUSION In children with acute leukaemia undergoing induction therapy, antibiotic prophylaxis may improve the bacterial infection and mortality.
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Affiliation(s)
- M Yang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China; Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China; NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; West China School of Medicine, Sichuan University, Chengdu, China
| | - X Lu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; Department of Paediatric Haematology and Oncology, West China Second Hospital, Sichuan University, Chengdu, China
| | - L Xin
- Department of Clinical Pharmacy, The Affiliated Hospital of Yunnan University, Kunming, China
| | - J Luo
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China; Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China; NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; West China School of Pharmacy, Sichuan University, Chengdu, China
| | - S Diao
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China; Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China; NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Z Jia
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China; Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China; NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; West China School of Pharmacy, Sichuan University, Chengdu, China
| | - G Cheng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China; Laboratory of Molecular Translational Medicine, Center for Translational Medicine, Sichuan University, Chengdu, China
| | - L Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China; Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China; NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China.
| | - L Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China; Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China; NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China.
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Safety of levofloxacin as an antibiotic prophylaxis in the induction phase of children newly diagnosed with acute lymphoblastic leukemia: an interim analysis of a randomized, open-label trial in Brazil. Braz J Infect Dis 2023; 27:102745. [PMID: 36750202 PMCID: PMC9978458 DOI: 10.1016/j.bjid.2023.102745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/14/2022] [Accepted: 01/05/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite high cure rates, treatment-related mortality in children with acute lymphoblastic leukemia (ALL) remains significant. About 4% of patients die during remission induction therapy and approximately two-thirds of treatment-related deaths are due to infectious complications. METHODS From May 2021 to June 2022, children aged one through 18 years, with a recent diagnosis of ALL, admitted to three pediatric oncology centers in Brazil, were enrolled in this multicenter, open-label, randomized, phase 3 clinical trial. Eligible patients were randomly divided into two groups, based on a 1:1 allocation ratio, to receive, or not, levofloxacin as a prophylactic agent during the induction phase. All patients were treated according to the IC-BFM 2009 chemotherapy protocol. Primary endpoints were carbapenemase-producing Enterobacteriaceae (CPE) colonization, Clostridioides difficile diarrhea, and other adverse events related to the use of levofloxacin. The secondary endpoint was febrile neutropenia during induction. The median follow-up was 289 days. RESULTS Twenty patients were included in this trial, 10 in each group (control and levofloxacin). Mild adverse reactions related to levofloxacin were observed in three patients (30%). Three patients had Clostridioides difficile diarrhea, two in the levofloxacin group and one in the control group (p > 0.99). Only one patient presented colonization by CPE. This patient belonged to the levofloxacin group (p > 0.99). Nine patients presented febrile neutropenia, five in the control group and four in the levofloxacin intervention group (p > 0.99), one patient died due to febrile neutropenia. CONCLUSION The use of levofloxacin was shown to be safe in the induction phase in children with de novo ALL. The use of this medication did not increase the rate of colonization by CPE nor the rate of diarrhea by C. difficile. All adverse reactions were mild and remitted either spontaneously or after switching medicine administration from oral to intravenous route.
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Hailu A, Mekasha A, Hailu D, Fentie AM, Korones DN, Gidey AM. Impact of Delay Prior to Treatment in Ethiopian Children with Acute Lymphoblastic Leukemia. Pediatric Health Med Ther 2023; 14:147-157. [PMID: 37197228 PMCID: PMC10184856 DOI: 10.2147/phmt.s406181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/01/2023] [Indexed: 05/19/2023] Open
Abstract
Introduction More than 85% of childhood malignancies occur in developing countries with less than a 30% cure rate as opposed to more than 80% cure rate in developed countries. This disproportionately significant difference might be due to delays in diagnosis, treatment initiation, lack of adequate supportive care, and treatment abandonment. We aimed to determine the impact of overall treatment delay on induction mortality of children with acute lymphoblastic leukemia treated at Tikur Anbessa specialized hospital (TASH). Methods A cross-sectional study was conducted among children who were treated from 2016 to 2019. Children with Down syndrome and relapsed leukemia were excluded from this study. Results A total of 166 children were included; most patients were males (71.7%). The mean age at diagnosis was 5.9 years. The median time interval from the onset of symptoms to the first TASH visit was 30 days and the median period from TASH's first clinic visit to diagnosis was 11 days. The median time to initiate chemotherapy after diagnosis was 8 days. The total median time from the first onset of symptoms to chemotherapy initiation was 53.5 days. Induction mortality was 31.3%. High-risk ALL and patients with an overall delay between 30 and 90 days were more likely to experience induction mortality. Discussion Patient and healthcare system delay is high compared to most studies done and a significant association has been noted with induction mortality. Efforts to expand the pediatric oncology service in the country and efficient diagnostic and treatment approach need to be established to reduce mortality associated with overall delay.
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Affiliation(s)
- Abel Hailu
- Department of Pediatrics and Child Health, Addis Ababa University Addis Ababa, Addis Ababa, Ethiopia
- Correspondence: Abel Hailu, Email
| | - Amha Mekasha
- Department of Pediatrics and Child Health, Addis Ababa University Addis Ababa, Addis Ababa, Ethiopia
| | - Daniel Hailu
- Department of Pediatrics and Child Health, Addis Ababa University Addis Ababa, Addis Ababa, Ethiopia
| | - Atalay Mulu Fentie
- Department of Pharmacology and Clinical Pharmacy, Addis Ababa University, Addis Ababa, Ethiopia
| | - David N Korones
- Department of Pediatrics, University of Rochester, New York, NY, USA
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Caro J, Madero-Marroquin R, Zubizarreta N, Moshier E, Tremblay D, Coltoff A, Lancman G, Fuller R, Rana M, Mascarenhas J, Jacobs SE. Impact of Fluoroquinolone Prophylaxis on Neutropenic Fever, Infections, and Antimicrobial Resistance in Newly Diagnosed AML Patients. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:903-911. [PMID: 36109322 DOI: 10.1016/j.clml.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Fluoroquinolone prophylaxis is recommended during induction chemotherapy for patients with acute myeloid leukemia (AML) to reduce risk of neutropenic fever and systemic bacterial infections. We evaluated the effectiveness of primary fluoroquinolone prophylaxis in an area with high fluoroquinolone resistance. MATERIALS AND METHODS We performed a retrospective chart review of newly diagnosed adult AML patients who received frontline therapy at Mount Sinai Hospital in New York, NY, between 2012 and 2019. Primary outcome was development of neutropenic fever. Secondary outcomes were development of systemic bacterial infections and infections with multidrug-resistant organisms and Clostridioides difficile. Infectious outcomes were collected through 6 months after therapy initiation. We estimated the effect of fluoroquinolone prophylaxis with a time-dependent Cox proportional hazards model. RESULTS Of 121 included patients, 87 received antibiotic prophylaxis and 34 did not. There was no difference in baseline characteristics, although the prophylaxis group had longer neutropenia duration (median 30 vs. 23 days, P = .013). The prophylaxis group had a reduced risk of neutropenic fever (hazard ratio 0.59, P = .039). The prophylaxis group had fewer gram-positive (P = .043) and gram-negative (P = .049) bloodstream infections and fewer clinically documented infections during frontline therapy (P = .005) and follow-up (P = .026). There was no difference in incidence of C. difficile or infection with fluoroquinolone-resistant or multidrug-resistant organisms. There was no mortality difference between groups. CONCLUSION In an area with high fluoroquinolone resistance, primary fluoroquinolone prophylaxis in newly diagnosed AML patients reduced the risk of neutropenic fever and systemic bacterial infections without increased antimicrobial resistance. Prospective, randomized studies are needed to confirm these observations.
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Affiliation(s)
- Jessica Caro
- Monter Cancer Center, Northwell Health, Lake Success, NY.
| | - Rafael Madero-Marroquin
- Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and Mount Sinai West, New York, NY
| | - Nicole Zubizarreta
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Erin Moshier
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alex Coltoff
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Guido Lancman
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Risa Fuller
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Meenakshi Rana
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Samantha E Jacobs
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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21
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Linder LA, Gerdy C, Jo Y, Stark C, Wilson A. Changes in Central Line–Associated Bloodstream Infection (CLABSI) Rates Following Implementation of Levofloxacin Prophylaxis for Children and Adolescents With High-Risk Leukemia. JOURNAL OF PEDIATRIC HEMATOLOGY/ONCOLOGY NURSING 2022; 40:69-81. [PMID: 36358024 DOI: 10.1177/27527530221122683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Despite initiatives to reduce central line–associated bloodstream infection (CLABSI), children and adolescents with hematologic malignancies, as well as those with relapsed disease, remain at the greatest risk for infection. This single-institution project evaluated changes in CLABSI rates following implementation of antibacterial prophylaxis with levofloxacin for patients with high-risk hematologic malignancies. Methods: Positive blood culture events meeting National Health Safety Network surveillance criteria to be classified as CLABSIs from January 1, 2006, to December 31, 2019, were included. Data were organized into four time periods for comparison based on implementation of CLABSI-reduction interventions. Conditional Poisson regression models were used to evaluate the effect of time (intervention period) on CLABSI rates with post hoc Tukey pairwise comparisons between each of the four time periods. Results: From 2006 and 2019, 227 patients experienced 310 CLABSIs. Clinically important decreases in CLABSI rates from baseline (4.84 per 1,000 line days) occurred with implementation of Children's Hospital Association (CHA) bundles (3.29 per 1,000 line days); however, this difference was not significant ( p = .16). CLABSI rates decreased from baseline with the addition of formalized supportive cares (2.66 per 1,000 line days; incidence rate ratio [IRR] = 0.60; p < .01), and with the use of antibacterial prophylaxis (1.66 per 1,000 line days; IRR = 0.35; p < .01). Post hoc comparisons indicated decreased CLABSI rates with the use of antibacterial prophylaxis compared with CHA bundles alone (IRR = 0.49; p = .011) and CHA bundles plus formalized supportive cares (IRR = 0.58; p = .046). Discussion: Results demonstrate sustained success using a practice-based evidence approach to guide CLABSI-reduction interventions. Follow-up research, applying machine learning algorithms, may identify additional risk factors and inform future interventions.
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Affiliation(s)
- Lauri A. Linder
- University of Utah College of Nursing, Salt Lake City, UT, USA
- Primary Children’s Hospital, Center for Cancer and Blood Disorders, Salt Lake City, UT, USA
| | - Cheryl Gerdy
- Primary Children’s Hospital, Center for Cancer and Blood Disorders, Salt Lake City, UT, USA
| | - Yeonjung Jo
- Huntsman Cancer Institute, Salt Lake City, UT, USA
- University of Utah School of Medicine, Population Health Sciences, Salt Lake City, UT, USA
| | - Crystal Stark
- Primary Children’s Hospital, Center for Cancer and Blood Disorders, Salt Lake City, UT, USA
| | - Andrew Wilson
- Parexel, Durham, NC, USA
- University of Utah Department of Family and Preventive Medicine, Salt Lake City, UT, USA
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22
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Leardini D, Muratore E, Abram N, Baccelli F, Belotti T, Prete A, Gori D, Masetti R. Effectiveness of Quinolone Prophylaxis in Pediatric Acute Leukemia and Hematopoietic Stem Cell Transplantation: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2022; 9:ofac594. [PMID: 36504701 PMCID: PMC9728521 DOI: 10.1093/ofid/ofac594] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
The effectiveness of quinolone prophylaxis in high-risk hematological pediatric patients is controversial. A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including studies that involved children and young adults undergoing chemotherapy for acute leukemia or hematopoietic stem cell transplantation (HSCT) who received quinolone prophylaxis compared with no prophylaxis. A meta-analysis was performed on bloodstream infections and neutropenic fever. Data regarding the impact of prophylaxis on overall survival, antibiotic exposure, antibiotic-related adverse effects, antibiotic resistance, Clostridium difficile infections, fungal infections, length of hospitalization, and costs were reviewed in the descriptive analysis. Sixteen studies were included in the qualitative analysis, and 10 of them met the criteria for quantitative analysis. Quinolone prophylaxis was effective in reducing the rate of bloodstream infections and neutropenic fever in pediatric acute leukemia compared with no prophylaxis, but it had no significant effect in HSCT recipients. Prophylaxis was associated with a higher rate of bacterial resistance to fluoroquinolones and higher antibiotic exposure.
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Affiliation(s)
| | | | - Nicoletta Abram
- Pediatric Oncology and Hematology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Baccelli
- Correspondence: F. Baccelli, MD, Pediatric Oncology and Hematology Unit “Lalla Seràgnoli,” Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Ospedale Policlinico S. Orsola-Malpighi, Via Massarenti 11, 40138 Bologna, Italy ()
| | - Tamara Belotti
- Pediatric Oncology and Hematology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Arcangelo Prete
- Pediatric Oncology and Hematology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Davide Gori
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
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23
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Villeneuve S, Aftandilian C. Neutropenia and Infection Prophylaxis in Childhood Cancer. Curr Oncol Rep 2022; 24:671-686. [PMID: 35230594 PMCID: PMC8885776 DOI: 10.1007/s11912-022-01192-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Pediatric oncology patients frequently experience episodes of prolonged neutropenia which puts them at high risk for infection with significant morbidity and mortality. Here, we review the data on infection prophylaxis with a focus on both pharmacologic and ancillary interventions. This review does not include patients receiving hematopoietic stem cell transplantation. RECENT FINDINGS Patients with hematologic malignancies are at highest risk for infection. Bacterial and fungal prophylaxis decrease the risk of infection in certain high-risk groups. Ancillary measures such as ethanol locks, chlorhexidine gluconate baths, GCSF, IVIG, and mandatory hospitalization do not have enough data to support routine use. There is limited data on risk of infection and role of prophylaxis in patients receiving immunotherapy and patients with solid tumors. Patients with Down syndrome and adolescent and young adult patients may benefit from additional supportive care measures and protocol modifications. Consider utilizing bacterial and fungal prophylaxis in patients with acute myeloid leukemia or relapsed acute lymphoblastic leukemia. More research is needed to evaluate other supportive care measures and the role of prophylaxis in patients receiving immunotherapy.
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Affiliation(s)
- Stephanie Villeneuve
- Paediatric Haemotology/Oncology, Dalhousie University and the IWK Health Centre, 5850/5980 University Avenue, Halifax, NS, B3K 6R8, Canada
| | - Catherine Aftandilian
- Pediatric Hematology/Oncology, Stanford University, 1000 Welch Rd, Palo Alto, CA, 94304, USA.
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24
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Servidio AG, Simeone R, Zanon D, Barbi E, Maximova N. Levofloxacin Versus Ciprofloxacin-Based Prophylaxis during the Pre-Engraftment Phase in Allogeneic Hematopoietic Stem Cell Transplant Pediatric Recipients: A Single-Center Retrospective Matched Analysis. Antibiotics (Basel) 2021; 10:antibiotics10121523. [PMID: 34943735 PMCID: PMC8698935 DOI: 10.3390/antibiotics10121523] [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: 10/31/2021] [Revised: 12/04/2021] [Accepted: 12/11/2021] [Indexed: 11/20/2022] Open
Abstract
Infectious complications are the most common and significant cause of mortality and morbidity after allogeneic hematopoietic stem cell transplantation (HSCT). Antibacterial prophylaxis in pediatric cancer patients is a controversial issue. Our study compared the outcomes of levofloxacin versus ciprofloxacin prophylaxis in allogeneic HSCT pediatric recipients treated for hematological malignancies. A total of 120 patients received levofloxacin prophylaxis, and 60 patients received ciprofloxacin prophylaxis. Baseline characteristics such as age, gender, primary diagnosis, type of conditioning, donor type, stem cell source, and supportive care of the patients were similar, and duration of antibiotics prophylaxis was similar. Both prophylaxis regimens demonstrated the same efficacy on the risk of febrile neutropenia and severe complications such as sepsis, the same rate of overall mortality, hospital readmission, and length of hospital stay. Levofloxacin prophylaxis was associated with significantly lower cumulative antibiotic exposure. The median of Gram-positive infection-related antibiotic days was 10 days in the levofloxacin group versus 25 days in the ciprofloxacin group (p < 0.0001). The median of Gram-negative infection-related antibiotics was 10 days in the levofloxacin group compared with 20 days in the ciprofloxacin group (p < 0.0001). The number of days with body temperature ≥38 °C was significantly less in the levofloxacin group (p < 0.001).
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Affiliation(s)
- Alessia G. Servidio
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Piazzale Europa 1, 34127 Trieste, Italy; (A.G.S.); (E.B.)
| | - Roberto Simeone
- Department of Transfusion Medicine, ASUGI, Piazza dell’Ospitale 1, 34125 Trieste, Italy;
| | - Davide Zanon
- Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Via dell’Istria 65/1, 34137 Trieste, Italy;
| | - Egidio Barbi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Piazzale Europa 1, 34127 Trieste, Italy; (A.G.S.); (E.B.)
- Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Via dell’Istria 65/1, 34137 Trieste, Italy;
| | - Natalia Maximova
- Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Via dell’Istria 65/1, 34137 Trieste, Italy;
- Correspondence: ; Tel.: +39-040-3785276 (ext. 565); Fax: +39-040-3785494
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25
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Lehrnbecher T, Fisher BT, Phillips B, Alexander S, Ammann RA, Beauchemin M, Carlesse F, Castagnola E, Davis BL, Dupuis LL, Egan G, Groll AH, Haeusler GM, Santolaya M, Steinbach WJ, van de Wetering M, Wolf J, Cabral S, Robinson PD, Sung L. Guideline for Antibacterial Prophylaxis Administration in Pediatric Cancer and Hematopoietic Stem Cell Transplantation. Clin Infect Dis 2021; 71:226-236. [PMID: 31676904 PMCID: PMC7312235 DOI: 10.1093/cid/ciz1082] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/29/2019] [Indexed: 11/27/2022] Open
Abstract
Background Bacteremia and other invasive bacterial infections are common among children with cancer receiving intensive chemotherapy and in pediatric recipients of hematopoietic stem cell transplantation (HSCT). Systemic antibacterial prophylaxis is one approach that can be used to reduce the risk of these infections. Our purpose was to develop a clinical practice guideline (CPG) for systemic antibacterial prophylaxis administration in pediatric patients with cancer and those undergoing HSCT. Methods An international and multidisciplinary panel was convened with representation from pediatric hematology/oncology and HSCT, pediatric infectious diseases (including antibiotic stewardship), nursing, pharmacy, a patient advocate, and a CPG methodologist. The panel used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to generate recommendations based on the results of a systematic review of the literature. Results The systematic review identified 114 eligible randomized trials of antibiotic prophylaxis. The panel made a weak recommendation for systemic antibacterial prophylaxis for children receiving intensive chemotherapy for acute myeloid leukemia and relapsed acute lymphoblastic leukemia (ALL). Weak recommendations against the routine use of systemic antibacterial prophylaxis were made for children undergoing induction chemotherapy for ALL, autologous HSCT and allogeneic HSCT. A strong recommendation against its routine use was made for children whose therapy is not expected to result in prolonged severe neutropenia. If used, prophylaxis with levofloxacin was recommended during severe neutropenia. Conclusions We present a CPG for systemic antibacterial prophylaxis administration in pediatric cancer and HSCT patients. Future research should evaluate the long-term effectiveness and adverse effects of prophylaxis.
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Affiliation(s)
- Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Brian T Fisher
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bob Phillips
- Leeds Children's Hospital, Leeds General Infirmary , Leeds Teaching Hospitals, NHS Trust, Leeds, United Kingdom.,Centre for Reviews and Dissemination, University of York, Leeds West Yorkshire, United Kingdom
| | - Sarah Alexander
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Roland A Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Melissa Beauchemin
- Columbia University/Herbert Irving Cancer Center, Pediatric Oncology, New York, New York, USA
| | - Fabianne Carlesse
- Pediatric Oncology Institute, GRAACC/Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, Istituto Giannina Gaslini, Genova, Italy
| | | | - L Lee Dupuis
- Department of Pharmacy, The Hospital for Sick Children, and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Grace Egan
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation, Department of Pediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany
| | - Gabrielle M Haeusler
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia
| | - Maria Santolaya
- Department of Pediatrics, Hospital Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - William J Steinbach
- Duke University Medical Center, Pediatric Infectious Diseases, Durham, North Carolina, USA
| | | | - Joshua Wolf
- Division of Infectious Diseases, St Jude's Children's Research Hospital, Memphis, Tennessee, USA
| | - Sandra Cabral
- Pediatric Oncology Group of Ontario, Toronto, Ontario, Canada
| | | | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
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26
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Partanen M, Phipps S, Russell K, Anghelescu DL, Wolf J, Conklin HM, Krull KR, Inaba H, Pui CH, Jacola LM. Longitudinal Trajectories of Neurocognitive Functioning in Childhood Acute Lymphoblastic Leukemia. J Pediatr Psychol 2021; 46:168-178. [PMID: 33011782 PMCID: PMC7896273 DOI: 10.1093/jpepsy/jsaa086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Children with acute lymphoblastic leukemia (ALL) are at risk for neurocognitive deficits, and examining individual variability is essential to understand these risks. This study evaluated latent longitudinal trajectories and risk factors of neurocognitive outcomes in childhood ALL. METHODS There were 233 participants with ALL who were enrolled on a phase 3, risk-stratified chemotherapy-only clinical trial (NCT00137111) and who completed protocol-directed neurocognitive assessments [47.6% female, mean (SD) = 6.6 (3.7) years]. Measures of sustained attention, learning/memory, and parent ratings of attention were completed during and after treatment. Longitudinal latent class analyses were used to classify participants into distinct trajectories. Logistic regression was used to identify predictors of class membership. RESULTS Within the overall group, attention performance was below age expectations across time (Conners Continuous Performance Test detectability/variability, p < 0.01); memory performance and parent ratings were below expectations at later phases (California Verbal Learning Test learning slope, p < 0.05; Conners Parent Rating Scale, Revised attention/learning, p < 0.05). Most participants (80-89%) had stable neurocognitive profiles; smaller groups showed declining (3-6%) or improving (3-11%) trajectories. Older age (p = 0.020), female sex (p = 0.018), and experiencing sepsis (p = 0.047) were associated with greater attention problems over time. Lower baseline IQ was associated with improved memory (p = 0.035) and fewer ratings of attention problems (p = 0.013) over time. CONCLUSIONS Most patients with ALL have stable neurocognitive profiles. Smaller groups have significant impairments shortly after diagnosis or have worsening performance over time. A tiered assessment approach, which includes consideration of individual and clinical risk factors, may be useful for monitoring neurocognitive functioning during treatment and survivorship.
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27
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Antibiotic prophylaxis and the gastrointestinal resistome in paediatric patients with acute lymphoblastic leukaemia: a cohort study with metagenomic sequencing analysis. LANCET MICROBE 2021; 2:e159-e167. [PMID: 34355208 PMCID: PMC8336918 DOI: 10.1016/s2666-5247(20)30202-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Although antibiotic prophylaxis with levofloxacin can reduce the risk of serious infection in immunocompromised patients, the potential contribution of prophylaxis to antibiotic resistance is a major drawback. We aimed to identify the effects of levofloxacin prophylaxis, given to paediatric patients with acute lymphoblastic leukaemia to prevent infections during induction chemotherapy, on antibiotic resistance in gastrointestinal microbiota after completion of induction and consolidation therapy. Methods This prospective, single-centre (St Jude Children's Research Hospital, Memphis, TN, USA) cohort study included children (≤18 years) receiving therapy for newly diagnosed acute lymphoblastic leukaemia and who received either primary levofloxacin prophylaxis or no antibacterial prophylaxis (aside from Pneumocystis jirovecii prophylaxis with trimethoprim-sulfamethoxazole) and provided at least two stool samples, including one after completion of induction therapy. We used metagenomic sequencing to identify bacterial genes that confer resistance to fluoroquinolones, trimethoprim-sulfamethoxazole, or other antibiotics, and to identify point mutations in bacterial topoisomerases (gyrA, parC) that confer resistance to fluoroquinolones. We then used generalised linear mixed models to compare the prevalence and relative abundance of antibiotic resistance gene groups after completion of induction and consolidation therapy between participants who had received levofloxacin and those who received no prophylaxis. Findings Between Feb 1, 2012, and April 30, 2016, 118 stool samples (32 baseline, 49 after induction, and 37 after consolidation) were collected from 49 evaluable participants; of these participants, 31 (63%) received levofloxacin prophylaxis during induction therapy and 18 (37%) received no antibacterial prophylaxis. Over the course of induction therapy, there was an overall increase in the relative abundance of trimethoprim-sulfamethoxazole resistance genes (estimated mean fold change 5·9, 95% CI 3·6-9·6; p<0·0001), which was not modified by levofloxacin prophylaxis (p=0·46). By contrast, the prevalence of topoisomerase point mutations increased over the course of induction therapy in levofloxacin recipients (mean prevalence 10·4% [95% CI 3·2-25·4] after induction therapy vs 3·7% [0·2-22·5] at baseline) but not other participants (0% vs 0%; p<0·0001). There was no significant difference between prophylaxis groups with respect to changes in aminoglycoside, β-lactam, vancomycin, or multidrug resistance genes after completion of induction or consolidation therapy. Interpretation Analysing the gastrointestinal resistome can provide insights into the effects of antibiotics on the risk of antibiotic-resistant infections. In this study, antibiotic prophylaxis with trimethoprim-sulfamethoxazole or levofloxacin during induction therapy for acute lymphoblastic leukaemia appeared to increase the short-term and medium-term risk of colonisation with bacteria resistant to these antibiotics, but not to other drugs. More research is needed to determine the longer-term effects of antibacterial prophylaxis on colonisation with antibiotic-resistant bacteria. Funding Children's Infection Defense Center at St Jude Children's Research Hospital, American Lebanese Syrian Associated Charities, and National Institutes of Health.
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28
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Olson J, Mehra S, Hersh AL, Thorell EA, Stoddard GJ, Maese L, Barnette PE, Lemons RS, Pavia AT, Knackstedt ED. Oral Step-Down Therapy With Levofloxacin for Febrile Neutropenia in Children With Cancer. J Pediatric Infect Dis Soc 2021; 10:27-33. [PMID: 32092134 DOI: 10.1093/jpids/piaa015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/03/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Although febrile neutropenia (FN) is a frequent complication in children with cancer receiving chemotherapy, there remains significant variability in selection of route (intravenous [IV] vs oral) and length of therapy. We implemented a guideline with a goal to change practice from using IV antibiotics after hospital discharge to the use of step-down oral therapy with levofloxacin for most children with FN until absolute neutrophil count > 500. The objectives of this study were to determine the impact of this guideline on home IV antibiotic use, and to evaluate the safety of implementation of this guideline. METHODS We performed a quasi-experimental, pre-post study of discharge FN treatment at a stand-alone children's hospital in patients without bacteremia discharged between January 2013 and October 2018. In January 2015, a multidisciplinary team created a guideline to switch most children with FN to oral levofloxacin, which was formally implemented as of September 2017. Discharges during the postintervention period (after September 2017) were compared to discharges in the preintervention period (between January 2013 and December 2014). RESULTS In adjusted multivariable regression analyses, the postimplementation period was associated with a decrease in home IV antibiotics (adjusted risk ratio [aRR], 0.07 [95% confidence interval {CI}, .03-.13]) and fewer IV antibiotic initiations within 24 hours of a new healthcare encounter up to 7 days after discharge (aRR, 0.39 [95% CI, .17-.93]) compared to the preintervention time period. CONCLUSIONS Step-down oral levofloxacin for children with FN who are afebrile with an ANC ≤ 500 at discharge is feasible and resulted in similar clinical outcomes compared to home IV antibiotics.
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Affiliation(s)
- Jared Olson
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, Utah, USA.,Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Sonia Mehra
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Emily A Thorell
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Gregory J Stoddard
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Luke Maese
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Phillip E Barnette
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Richard S Lemons
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Elizabeth D Knackstedt
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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29
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Early T-Cell Precursor Leukemia Has a Higher Risk of Induction-Related Infection among T-Cell Acute Lymphoblastic Leukemia in Adult. Mediators Inflamm 2021; 2020:8867760. [PMID: 33424437 PMCID: PMC7775137 DOI: 10.1155/2020/8867760] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/10/2020] [Accepted: 12/10/2020] [Indexed: 11/17/2022] Open
Abstract
Background Infections are an important cause of morbidity and mortality for acute lymphoblastic leukemia (ALL). However, the reports regarding risk factors of induction-related infection are roughly unknown/limited in adult T-ALL during induction chemotherapy. Methods We performed a retrospective cohort study for the prevalence and risk predictors of induction-related infection among consecutive T-ALL patients (N = 97) enrolled in a PDT-ALL-LBL clinical trial. Of 97 patients with T-ALL enrolled in the trial, 46 were early T-cell precursor (ETP) ALL and 51 were non-ETP ALL. Results When compared with non-ETP, ETP ALL subtype was characterized with lower neutrophil count (1.35 × 109/L vs. 8.7 × 109/L, P < 0.001) and lower myeloid percentage in the bone marrow (13.35% vs. 35.31%, P = 0.007). Additionally, ETP ALL had longer neutropenia before diagnosis (P < 0.001), as well as during induction chemotherapy (P < 0.001). Notably, the ETP cohort experienced higher cumulative incidence of clinically documented infections (CDI; 33.33%, P = 0.001), microbiologically documented infections (MDI; 45.24%, P = 0.006), resistant infection (11.9%, P = 0.013), and mixed infection (21.43%, P = 0.003), respectively, than those of the non-ETP cohort. Furthermore, multivariable analysis revealed that T-ALL mixed infection was more likely related to chemotherapy response (OR, 0.025; 95% CI 0.127-0.64; P = 0.012) and identified myeloid percentage as a predictor associated with ETP-ALL mixed infection (OR, 0.915; 95% CI 0.843-0.993; P = 0.033), with ROC-defined cut-off value of 2.24% in ETP cohorts. Conclusions Our data for the first time demonstrated that ETP-ALL characterized with impaired myelopoiesis were more susceptible to induction-related infection among T-ALL populations.
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30
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Busca A, Cattaneo C, De Carolis E, Nadali G, Offidani M, Picardi M, Candoni A, Ceresoli E, Criscuolo M, Delia M, Della Pepa R, Del Principe I, Fanci RR, Farina F, Fracchiolla N, Giordano C, Malagola M, Marchesi F, Piedimonte M, Prezioso L, Quinto AM, Spolzino A, Tisi MC, Trastulli F, Trecarichi EM, Zappasodi P, Tumbarello M, Pagano L. Considerations on antimicrobial prophylaxis in patients with lymphoproliferative diseases: A SEIFEM group position paper. Crit Rev Oncol Hematol 2020; 158:103203. [PMID: 33388453 DOI: 10.1016/j.critrevonc.2020.103203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 11/15/2020] [Accepted: 12/20/2020] [Indexed: 11/16/2022] Open
Abstract
The therapeutic armamentarium for the treatment of patients with lymphoproliferative diseases has grown considerably over the most recent years, including a large use of new immunotherapeutic agents. As a consequence, the epidemiology of infectious complications in this group of patients is poorly documented, and even more importantly, the potential benefit of antimicrobial prophylaxis remains a matter of debate when considering the harmful effect from the emergence of multidrug resistant pathogens. The present position paper is addressed to all hematologists treating patients affected by lymphoproliferative malignancies with the aim to provide clinicians with a useful tool for the prevention of bacterial, fungal and viral infections.
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Affiliation(s)
- Alessandro Busca
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy.
| | - Chiara Cattaneo
- Divisione di Ematologia, ASST-Spedali Civili di Brescia, Brescia, Chiara, Italy.
| | - Elena De Carolis
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.
| | - Gianpaolo Nadali
- U.O.C. Ematologia, AOU Integrata di Verona, Ospedale Borgo Roma, Verona, Italy.
| | - Massimo Offidani
- Clinica di Ematologia, AOU Ospedali Riuniti di Ancona, Ancona, Italy.
| | - Marco Picardi
- Department of Advanced Biomedical Science, Federico II University, Italy.
| | - Anna Candoni
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari, Azienda Sanitaria Universitaria Integrata di Udine, Italy.
| | - Eleonora Ceresoli
- Ematologia Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy.
| | - Marianna Criscuolo
- Dipartimento di scienze radiologiche, radioterapiche ed ematologiche Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Italy.
| | - Mario Delia
- U.O.: Ematologia con Trapianto Azienda Ospedaliero-Universitaria Dipartimento dell'Emergenza e Dei Trapianti di Organo Policlinico di Bari, Italy.
| | - Roberta Della Pepa
- Department of Clinical Medicine and Surgery", University of Federico II Naples, Italy.
| | - Ilaria Del Principe
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università degli studi di Roma "Tor Vergata", Italy.
| | - Roma Rosa Fanci
- Hematology Department, Careggi Hospital and University of Florence, Italy.
| | - Francesca Farina
- U.O. Ematologia e Trapianto di Midollo - IRCCS Ospedale San Raffaele, Milano, Italy.
| | - Nicola Fracchiolla
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Italy.
| | - Claudia Giordano
- Department of Clinical Medicine and Surgery", University of Federico II Naples, Italy.
| | - Michele Malagola
- Department of Clinical and Experimental Sciences, University of Brescia, Bone Marrow Transplant Unit, ASST Spedali Civili of Brescia, Italy.
| | - Francesco Marchesi
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy.
| | - Monica Piedimonte
- Department of Clinical and Molecular Medicine, Hematology Sant'Andrea University Hospital, Sapienza University of Rome, Italy.
| | - Lucia Prezioso
- Hematology and BMT Unit, Azienda Ospedaliero-Universitaria di Parma and Department of Medicine and Surgery, University of Parma, Italy.
| | - Angela Maria Quinto
- UO Ematologia e Terapia Cellulare, IRCCS - Istituto Tumori "Giovanni Paolo II" Bari, Italy.
| | - Angelica Spolzino
- Department of Clinical and Molecular Medicine, Hematology Sant'Andrea University Hospital, Sapienza University of Rome, Italy.
| | | | - Fabio Trastulli
- Department of Clinical Medicine and Surgery", University of Federico II Naples, Italy.
| | - Enrico Maria Trecarichi
- Dipartimento di Scienze Mediche e Chirurgiche, UO Malattie Infettive e Tropicali, Università degli Studi "Magna Graecia", Catanzaro, Italy.
| | - Patrizia Zappasodi
- Division of Hematology, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
| | - Mario Tumbarello
- Fondazione Policlinico Universitario A. Gemelli - IRCCS - Istituto di Malattie Infettive -Università Cattolica del Sacro Cuore, Livio, Italy.
| | - Livio Pagano
- Fondazione Policlinico Universitario A. Gemelli - IRCCS - Istituto di Malattie Infettive -Università Cattolica del Sacro Cuore, Livio, Italy.
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Goggin KP, Gonzalez-Pena V, Inaba Y, Allison KJ, Hong DK, Ahmed AA, Hollemon D, Natarajan S, Mahmud O, Kuenzinger W, Youssef S, Brenner A, Maron G, Choi J, Rubnitz JE, Sun Y, Tang L, Wolf J, Gawad C. Evaluation of Plasma Microbial Cell-Free DNA Sequencing to Predict Bloodstream Infection in Pediatric Patients With Relapsed or Refractory Cancer. JAMA Oncol 2020; 6:552-556. [PMID: 31855231 PMCID: PMC6990667 DOI: 10.1001/jamaoncol.2019.4120] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Question Might plasma microbial cell-free DNA sequencing (mcfDNA-seq) predict bloodstream infection (BSI) in immunocompromised patients days before the onset of attributable symptoms? Findings This pilot cohort study included 47 pediatric patients with relapsed or refractory cancer. The causative pathogen was identified by mcfDNA-seq in the 3 days before onset of BSI in 12 of 16 episodes; of 33 negative control samples collected from the same patient population, mcfDNA-seq was negative in 27 and identified no common pathogens in 30. Meaning In patients with imminent BSI, it appears that mcfDNA-seq can identify clinically relevant pathogens days before onset of attributable symptoms. Importance Bloodstream infection (BSI) is a common, life-threatening complication of treatment for cancer. Predicting BSI before onset of clinical symptoms would enable preemptive therapy, but there is no reliable screening test. Objective To estimate sensitivity and specificity of plasma microbial cell-free DNA sequencing (mcfDNA-seq) for predicting BSI in patients at high risk of life-threatening infection. Design, Setting, and Participants A prospective pilot cohort study of mcfDNA-seq for predicting BSI in pediatric patients (<25 years of age) with relapsed or refractory cancers at St Jude Children’s Research Hospital, a specialist quaternary pediatric hematology-oncology referral center. Remnant clinical blood samples were collected during chemotherapy and hematopoietic cell transplantation. Samples collected during the 7 days before and at onset of BSI episodes, along with negative control samples from study participants, underwent blinded testing using a mcfDNA-seq test in a Clinical Laboratory Improvement Amendments/College of American Pathologists–approved laboratory. Main Outcomes and Measures The primary outcomes were sensitivity of mcfDNA-seq for detecting a BSI pathogen during the 3 days before BSI onset and specificity of mcfDNA-seq in the absence of fever or infection in the preceding or subsequent 7 days. Results Between August 9, 2017, and June 4, 2018, 47 participants (27 [57%] male; median age [IQR], 10 [5-14] years) were enrolled; 19 BSI episodes occurred in 12 participants, and predictive samples were available for 16 episodes, including 15 bacterial BSI episodes. In the 3 days before the onset of infection, predictive sensitivity of mcfDNA-seq was 75% for all BSIs (12 of 16; 95% CI, 51%-90%) and 80% (12 of 15; 95% CI, 55%-93%) for bacterial BSIs. The specificity of mcfDNA-seq, evaluated on 33 negative control samples from enrolled participants, was 82% (27 of 33; 95% CI, 66%-91%) for any bacterial or fungal organism and 91% (30 of 33; 95% CI, 76%-97%) for any common BSI pathogen, and the concentration of pathogen DNA was lower in control than predictive samples. Conclusions and Relevance A clinically relevant pathogen can be identified by mcfDNA-seq days before the onset of BSI in a majority of episodes, potentially enabling preemptive treatment. Clinical application appears feasible pending further study. Trial Registration ClinicalTrials.gov identifier: NCT03226158
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Affiliation(s)
- Kathryn P Goggin
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Yuki Inaba
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Kim J Allison
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | | | | | | | - Sivaraman Natarajan
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Ousman Mahmud
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - William Kuenzinger
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Sarah Youssef
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Abigail Brenner
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Gabriela Maron
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | - John Choi
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Jeffrey E Rubnitz
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Pediatrics, The University of Tennessee Health Science Center, Memphis
| | - Yilun Sun
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Li Tang
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Joshua Wolf
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Pediatrics, The University of Tennessee Health Science Center, Memphis.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Charles Gawad
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Pediatrics, The University of Tennessee Health Science Center, Memphis.,Department of Computational Biology, St Jude Children's Research Hospital, Memphis, Tennessee
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32
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Shen S, Chen X, Cai J, Yu J, Gao J, Hu S, Zhai X, Liang C, Ju X, Jiang H, Jin R, Wu X, Wang N, Tian X, Pan K, Jiang H, Sun L, Fang Y, Li CK, Hu Q, Yang M, Zhu Y, Zhang H, Li C, Pei D, Jeha S, Yang JJ, Cheng C, Tang J, Zhu X, Pui CH. Effect of Dasatinib vs Imatinib in the Treatment of Pediatric Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia: A Randomized Clinical Trial. JAMA Oncol 2020; 6:358-366. [PMID: 31944221 DOI: 10.1001/jamaoncol.2019.5868] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance A randomized clinical trial is needed to determine whether the second-generation Abl-tyrosine kinase inhibitor dasatinib is more effective than the first-generation inhibitor imatinib mesylate for childhood Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL). Objective To determine whether dasatinib given at a daily dosage of 80 mg/m2 is more effective than imatinib mesylate at a daily dosage of 300 mg/m2 to improve event-free survival of children with Philadelphia chromosome-positive ALL in the context of intensive chemotherapy without prophylactic cranial irradiation. Design, Setting, and Participants This open-label, phase 3 randomized clinical trial was conducted at 20 hospitals in China. Enrollment occurred from January 1, 2015, through September 18, 2018, and randomization was stopped on October 4, 2018, when the early stopping criterion of the trial was met. Patients aged 0 to 18 years were recruited. Of the 225 patients with the diagnosis, 35 declined participation and 1 died before treatment, leaving 189 patients available for analysis. Data were analyzed from January 1 through August 4, 2019. Interventions Patients were randomized to receive daily dasatinib (n = 92) or imatinib (n = 97) continuously for the entire duration of ALL therapy from the time of diagnosis made during remission induction to the end of continuation therapy. Main Outcomes and Measures The primary outcome was event-free survival, analyzed based on intention to treat. The secondary outcomes were relapse, death due to toxic effects, and overall survival. Results Among the 189 participants (136 male [72.0%]; median age, 7.8 [interquartile range (IQR), 5.2-11.3] years) and a median follow-up of 26.4 (IQR, 16.3-34.1) months, the 4-year event-free survival and overall survival rates were 71.0% (95% CI, 56.2%-89.6%) and 88.4% (95% CI, 81.3%-96.1%), respectively, in the dasatinib group and 48.9% (95% CI, 32.0%-74.5%; P = .005, log-rank test) and 69.2% (95% CI, 55.6%-86.2%; P = .04, log-rank test), respectively, in the imatinib group. The 4-year cumulative risk of any relapse was 19.8% (95% CI, 4.2%-35.4%) in the dasatinib group and 34.4% (95% CI, 15.6%-53.2%) in the imatinib group (P = .01, Gray test), whereas the 4-year cumulative risk of an isolated central nervous system relapse was 2.7% (95% CI, 0.0%-8.1%) in the dasatinib group and 8.4% (95% CI, 1.2%-15.6%) in the imatinib group (P = .06, Gray test). There were no significant differences in the frequency of severe toxic effects between the 2 treatment groups. Conclusions and Relevance Intensive chemotherapy including dasatinib at a dosage of 80 mg/m2 per day yielded superior results in the treatment of Philadelphia chromosome-positive ALL compared with imatinib mesylate at a dosage of 300 mg/m2 per day and provided excellent control of central nervous system leukemia without the use of prophylactic cranial irradiation. Trial Registration Chinese Clinical Trial Registry: ChiCTR-IPR-14005706.
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Affiliation(s)
- Shuhong Shen
- National Children's Medical Center, Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaojuan Chen
- State Key Laboratory of Experimental Hematology and Division of Pediatric Blood Diseases Center, Institute of Hematology and Blood Diseases Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Tianjin, China
| | - Jiaoyang Cai
- National Children's Medical Center, Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Yu
- Department of Hematology/Oncology, Chongqing Medical University Affiliated Children's Hospital, Chongqing, China
| | - Ju Gao
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Disease of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Shaoyan Hu
- Department of Hematology/Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Xiaowen Zhai
- Department of Hematology/Oncology, Children's Hospital of Fudan University, Shanghai, China
| | - Changda Liang
- Department of Hematology/Oncology, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Xiuli Ju
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Hua Jiang
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Runming Jin
- Department of Pediatrics, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuedong Wu
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ningling Wang
- Department of Pediatrics, Anhui Medical University Second Affiliated Hospital, Anhui, China
| | - Xin Tian
- Department of Hematology/Oncology, Kunming Children's Hospital, Kunming, China
| | - Kaili Pan
- Department of Hematology/Oncology, Xi'an Northwest Women and Children Hospital, Xi'an, China
| | - Hui Jiang
- Department of Hematology/Oncology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lirong Sun
- Department of Pediatrics, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yongjun Fang
- Department of Hematology/Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Chi-Kong Li
- Department of Pediatrics, Hong Kong Children's Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Qun Hu
- Department of Pediatrics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Minghua Yang
- Department of Pediatrics, Xiangya Hospital Central South University, Changsha, China
| | - Yiping Zhu
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Disease of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Hui Zhang
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Chunfu Li
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Deqing Pei
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Sima Jeha
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Jun J Yang
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Cheng Cheng
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Jingyan Tang
- National Children's Medical Center, Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaofan Zhu
- State Key Laboratory of Experimental Hematology and Division of Pediatric Blood Diseases Center, Institute of Hematology and Blood Diseases Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Tianjin, China
| | - Ching-Hon Pui
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
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West ZE, Castellino SM, Monroe C, Thomas AS, McCracken C, Miller TP. Quantifying the difference in risk of adverse events by induction treatment regimen in pediatric acute lymphoblastic leukemia. Leuk Lymphoma 2020; 62:899-908. [PMID: 33258395 DOI: 10.1080/10428194.2020.1852471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The differences in overall morbidity by induction treatment regimen for pediatric acute lymphoblastic leukemia (ALL) are unknown. We examined a cohort of children with ALL who received induction chemotherapy between January 2010 and May 2018. We evaluated 20 clinically relevant adverse events (AEs) and readmission and ICU admission rates. Outcomes were compared between standard 3- and 4-drug treatment regimens in multivariate analyses using Cox proportional hazard ratios. Among 486 eligible patients, the risks of sepsis (HR = 2.16, 95% CI = 1.11-4.19), hypoxia (HR = 2.08, 95% CI = 1.03-4.18), hyperbilirubinemia (HR = 2.48, 95% CI = 1.07-5.74), hyperglycemia (HR = 2.65, 95% CI = 1.29-5.42), thromboembolic event (HR = 4.50, 95% CI = 1.30-15.6), and hyponatremia (HR = 7.88, 95% CI = 1.26-49.4) were significantly higher during 4-drug induction. Despite no differences in readmission or ICU admission rates, 4-drug induction patients had greater total inpatient days (12 vs. 4 days; p<.0001). In conclusion, pediatric patients receiving 4-drug induction for ALL experience higher morbidity. These results inform care practices and patient guidance during induction therapy.
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Affiliation(s)
- Zachary E West
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Sharon M Castellino
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Caitlin Monroe
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Amanda S Thomas
- Department of Pediatrics, Biostatistics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Department of Pediatrics, Biostatistics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Tamara P Miller
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Resistance to Antibiotics of Uropathogen Bacteria Isolated From Urine and Blood in Pediatric Cancer Patients: A Single Center, 12-year Study. Pediatr Infect Dis J 2020; 39:1106-1110. [PMID: 33021597 DOI: 10.1097/inf.0000000000002854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Resistant pathogens have become a major healthcare problem in children with cancer, causing different kinds of infections such as the bloodstream ones, most common, and most frequently described and the urinary tract ones, of which less data are available. We analyzed and compared the proportions, and the trends of resistance in pathogens isolated from blood and urines in children with cancer followed in IRCCS Istituto Giannina Gaslini, Genova, Italy, from January 2007 to December 2018. Overall, 345 strains detected in urines and 282 in bloodstream infections were analyzed. Enterobacteriales were the most frequently isolated pathogens. During the study period in urines, there was a significant increase of resistance to ceftazidime, ciprofloxacin, piperacillin/tazobactam, and trimethoprim-sulfamethoxazole, but pathogens from blood were significantly more frequently resistant to amikacin, piperacillin/tazobactam, and combination therapy piperacillin/tazobactam+amikacin, even if with a decreasing trend during the study period. These data confirm the importance of surveillance of isolated microorganism and antibiotic resistance in cancer children.
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Abstract
The last decade has witnessed great advances in our understanding of the genetic and biological basis of childhood acute lymphoblastic leukemia (ALL), the development of experimental models to probe mechanisms and evaluate new therapies, and the development of more efficacious treatment stratification. Genomic analyses have revolutionized our understanding of the molecular taxonomy of ALL, and these advances have led the push to implement genome and transcriptome characterization in the clinical management of ALL to facilitate more accurate risk-stratification and, in some cases, targeted therapy. Although mutation- or pathway-directed targeted therapy (e.g., using tyrosine kinase inhibitors to treat Philadelphia chromosome [Ph]-positive and Phlike B-cell-ALL) is currently available for only a minority of children with ALL, many of the newly identified molecular alterations have led to the exploration of approaches targeting deregulated cell pathways. The efficacy of cellular or humoral immunotherapy has been demonstrated with the success of chimeric antigen receptor T-cell therapy and the bispecific engager blinatumomab in treating advanced disease. This review describes key advances in our understanding of the biology of ALL and optimal approaches to risk-stratification and therapy, and it suggests key areas for basic and clinical research.
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Affiliation(s)
- Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN; Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, TN.
| | - Charles G Mullighan
- Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, TN; Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN.
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36
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Patel B, Noda A, Godbout E, Stevens M, Noda C. Levofloxacin for Antibacterial Prophylaxis in Pediatric Patients With Acute Myeloid Leukemia or Undergoing Hematopoietic Stem Cell Transplantation. J Pediatr Pharmacol Ther 2020; 25:629-635. [PMID: 33041718 DOI: 10.5863/1551-6776-25.7.629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study aimed to evaluate the use of levofloxacin for the prevention of bacterial infections in pediatric patients with acute myeloid leukemia or those undergoing hematopoietic stem cell transplantation. METHODS This study was a single-center, retrospective review designed to assess the frequency of bacteremia with levofloxacin prophylaxis compared with historical controls that used other, clinician-directed antibacterial prophylaxis. The primary outcome of the study was microbiologically documented bacteremia. Secondary outcomes included febrile neutropenia, clinically documented infection, duration of neutropenia, treatment antibiotic exposure days, Clostridioides difficile infection, and infection-related mortality. RESULTS Of the 60 patients included, 24 patients with 32 hospital admissions received levofloxacin and 36 patients with 48 hospital admissions received clinician-directed prophylaxis. There was no difference found in the frequency of bacteremia between levofloxacin and clinician-directed prophylaxis (15.6% vs 10.4%, p = 0.49). There was no difference in the incidence of febrile neutropenia, clinically documented infection, treatment antibiotic exposure days, or 30-day infection-related mortality between the 2 groups. The levofloxacin group had a longer mean duration of neutropenia compared with clinician-directed prophylaxis (26.8 days vs 16.4 days, p = 0.01). CONCLUSIONS There was no difference in bacteremia between levofloxacin prophylaxis and clinician-directed prophylaxis in pediatric patients with acute myeloid leukemia or those undergoing hematopoietic stem cell transplantation. Levofloxacin prophylaxis is an appropriate alternative for the prevention of serious bacterial infections in this patient population, although further studies are needed to confirm these results.
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Maser B, Pelland-Marcotte MC, Alexander S, Sung L, Gupta S. Levofloxacin prophylaxis in hospitalized children with leukemia: A cost-utility analysis. Pediatr Blood Cancer 2020; 67:e28643. [PMID: 32785971 DOI: 10.1002/pbc.28643] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Infections are common and are a major cause of morbidity and mortality during treatment of childhood leukemia. We evaluated the cost effectiveness of levofloxacin antibiotic prophylaxis, compared to no prophylaxis, in children receiving chemotherapy for acute myeloid leukemia (AML) or relapsed acute lymphoblastic leukemia (ALL). PROCEDURES A cost-utility analysis was conducted from the perspective of the single-payer health care system using a lifetime horizon. A comprehensive literature review identified available evidence for effectiveness, safety, costs of antibiotic prophylaxis in children with leukemia, and health utilities associated with the relevant health states. The effects of levofloxacin prophylaxis on health outcomes, quality-adjusted life-years (QALY), and direct health costs were derived from a combined decision tree and state-transition model. One-way deterministic and probabilistic sensitivity analyses were performed to test the sensitivity of results to parameter uncertainty. RESULTS The literature review revealed one randomized controlled trial on levofloxacin prophylaxis in childhood AML and relapsed ALL, by Alexander et al, that showed a significant reduction in rates of fever and neutropenia (71.2% vs 82.1%) and bacteremia (21.9% vs 43.4%) with levofloxacin compared to no prophylaxis. In our cost-utility analysis, levofloxacin prophylaxis was dominant over no prophylaxis, resulting in cost savings of $542.44 and increased survival of 0.13 QALY. In probabilistic sensitivity analysis, levofloxacin prophylaxis was dominant in 98.8% of iterations. CONCLUSIONS The present analysis suggests that levofloxacin prophylaxis, compared to no prophylaxis, is cost saving in children receiving intensive chemotherapy for AML or relapsed ALL.
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Affiliation(s)
- Brandon Maser
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Marie-Claude Pelland-Marcotte
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,CHU de Québec - Centre Mère-Enfant Soleil, Quebec City, Quebec, Canada
| | | | - Lillian Sung
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Sumit Gupta
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
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38
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McCormick M, Friehling E, Kalpatthi R, Siripong N, Smith K. Cost-effectiveness of levofloxacin prophylaxis against bacterial infection in pediatric patients with acute myeloid leukemia. Pediatr Blood Cancer 2020; 67:e28469. [PMID: 32710709 PMCID: PMC7722035 DOI: 10.1002/pbc.28469] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/08/2020] [Accepted: 05/18/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infections are the leading cause of therapy-related mortality in pediatric patients with acute myeloid leukemia (AML). Although effectiveness of levofloxacin antibacterial prophylaxis in oncology patients is recognized, its cost-effectiveness is unknown. This study evaluated epidemiologic data regarding levofloxacin use and the cost-effectiveness of this strategy as the cost per bacteremia episode, intensive care unit (ICU) admission, and death avoided in children with AML. PROCEDURE A retrospective cohort study using the Pediatric Health Information System (PHIS) database compared demographic and clinical characteristics and receipt of levofloxacin prophylaxis in children with AML admitted for chemotherapy from January 1, 2014, through December 31, 2018. We then developed a decision analysis model in this population that compared costs associated with bacteremia, ICU admission, or death secondary to bacteremia to levofloxacin prophylaxis cost from a healthcare perspective. Time horizon is one chemotherapy cycle. Probabilistic and one-way sensitivity analyses evaluated model uncertainty. RESULTS Prophylaxis cost $8491 per bacteremia episode prevented compared with an average added hospital cost of $119 478. Prophylaxis cost $81 609 per ICU admission avoided, compared with an average added hospital cost of $94 181. Prophylaxis cost $220 457 per death avoided. In sensitivity analysis, at a willingness-to-pay threshold of $100 000 per bacteremia episode avoided, prophylaxis remained cost-effective in 94.6% of simulations. Prophylaxis use was more common in recent years in patients with relapsed disease and with chemotherapy regimens considered more intensive. CONCLUSION Prophylaxis is cost-effective in preventing bacterial infections in patients with AML. Findings support increased use in patients considered at high risk of bacterial infection secondary to myelosuppression.
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Affiliation(s)
- Meghan McCormick
- Division of Pediatric Hematology-Oncology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erika Friehling
- Division of Pediatric Hematology-Oncology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ramasubramanian Kalpatthi
- Division of Pediatric Hematology-Oncology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nalyn Siripong
- The Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kenneth Smith
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Antibiotic use during cytarabine consolidation in acute myeloid leukemia. Ann Hematol 2020; 100:79-84. [PMID: 32870366 DOI: 10.1007/s00277-020-04238-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/26/2020] [Indexed: 10/23/2022]
Abstract
Acute myeloid leukemia (AML) patients undergoing consolidation chemotherapy with intermediate or high-dose cytarabine (IDAC/HiDAC) are often placed on prophylactic antibacterials. This practice is largely based on the benefits of prophylaxis (PPX) during induction chemotherapy. However, recent concerns regarding antibacterial prophylaxis have emerged including risk of Clostridioides difficile colitis, medication toxicities, and the potential for fostering multidrug-resistant pathogens. We therefore retrospectively explored whether antibacterial PPX is beneficial during cytarabine consolidation. Adult AML patients who received IDAC/HiDAC at our institution from January 2007 to March 2018 were evaluated for receipt of antibacterial PPX. The primary endpoint was rate of febrile neutropenia (FN); secondary endpoints were rates of unplanned hospitalization, bacteremia, infection from resistant organisms, C. difficile colitis, and death from infection. One hundred twenty patients with data from 229 IDAC/HiDAC cycles were included. Patients who received antibacterial PPX were more often hospitalized during cytarabine cycle 1 (C1) than those who received no PPX. Patients who received PPX had significantly more episodes of bacteremia, in addition to infections from resistant, predominantly Gram-positive organisms during cycle 1 of consolidation than those without PPX. Antibacterial PPX during IDAC/HiDAC consolidation treatment at our institution did not decrease the rates of FN, hospitalization, or bacteremia and was associated with higher risk of infection from drug-resistant bacteria in C1. Prospective studies examining antibacterial prophylaxis during cytarabine consolidation for AML patients are necessary, with strong consideration made for institution-specific protocols.
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Emergency Combination of Four Drugs for Bloodstream Infection Caused by Carbapenem-Resistant Enterobacteriaceae in Severe Agranulocytosis Patients with Hematologic Malignancies after Hematopoietic Stem Cell Transplantation. Emerg Med Int 2020; 2020:9358426. [PMID: 32832159 PMCID: PMC7424386 DOI: 10.1155/2020/9358426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/24/2020] [Accepted: 06/06/2020] [Indexed: 11/18/2022] Open
Abstract
Bloodstream infection (BSI) caused by multidrug-resistant (MDR) bacteria or extensively drug-resistant (XDR) bacteria is a global threat. However, an effective treatment regimen is still controversial and inadequate due to the rapid deterioration caused by the bacteria. In immunocompromised and neutropenic patients, MDR-BSI is an emergency, which causes treatment-related mortality. In this study, four agranulocytosis patients with hematologic malignancies after HSCT receiving treatment for carbapenem-resistant Enterobacteriaceae- (CRE-) BSI were included. Conventional treatment using two to three combined antibiotics was administered in the first and second patients. Combination treatment using four drugs, polymyxin B, high-dose tigecycline, fosfomycin, and double-dose carbapenem, was administered in the third and fourth patients. None of the patients receiving conventional treatment survived. Both patients receiving combination treatment using four drugs survived. Therefore, four-drug combination therapy may be needed in CRE-BSI patients who experienced severe agranulocytosis after HSCT. The efficacy of the four-drug combination treatment for CRE-BSI patients as well as the adverse effects need to be further studied.
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Wang JG, Cui HR, Hu YS, Tang HB. Assessment of the risk of musculoskeletal adverse events associated with fluoroquinolone use in children: A meta-analysis. Medicine (Baltimore) 2020; 99:e21860. [PMID: 32846837 PMCID: PMC7447478 DOI: 10.1097/md.0000000000021860] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The use of fluoroquinolone antibiotics has been restricted in children because of their potential to cause adverse musculoskeletal events. This study was performed to systematically evaluate whether there is a difference between fluoroquinolone and non-fluoroquinolone antibiotics in terms of their associated risk of adverse musculoskeletal events in children. METHODS Cochrane Library, Embase, and PubMed databases were used to retrieve studies related to fluoroquinolone and non-fluoroquinolone-induced musculoskeletal adverse events in children. A meta-analysis was performed using Stata 11. RESULTS A total of 10 studies were included in the analysis. The combined results showed that there was no statistical difference between fluoroquinolone and non-fluoroquinolone groups in terms of musculoskeletal adverse events in children (risk ratio = 1.145, 95% confidence interval = 0.974 - 1.345, P = .101). Subgroup analysis was performed using a random-effects model. Here, the effects on the trovafloxacin and levofloxacin groups were significantly different from that of the control group. However, musculoskeletal adverse events due to either drug was not reported after long-term follow-up. CONCLUSIONS The results showed that fluoroquinolone and non-fluoroquinolone antibiotics were not different in terms of their ability to cause musculoskeletal adverse events in children. For this reason, fluoroquinolone antibiotics can be used in children as appropriate. PROSPERO REGISTRATION NUMBER CRD42019133900.
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Affiliation(s)
- Ji-gan Wang
- Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning
| | - Hai-Rong Cui
- The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yi-sen Hu
- The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Hua-Bo Tang
- Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning
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42
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Mayer EF, Maron G, Dallas RH, Ferrolino J, Tang L, Sun Y, Danziger-Isakov L, Paulsen GC, Fisher BT, Vora SB, Englund J, Steinbach WJ, Michaels M, Green M, Yeganeh N, Gibson JE, Dominguez SR, Nicholson MR, Dulek DE, Ardura MI, Rajan S, Gonzalez BE, Beneri C, Herold BC. A multicenter study to define the epidemiology and outcomes of Clostridioides difficile infection in pediatric hematopoietic cell and solid organ transplant recipients. Am J Transplant 2020; 20:2133-2142. [PMID: 32064754 DOI: 10.1111/ajt.15826] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 01/25/2023]
Abstract
Hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients are at increased risk for Clostridioides difficile infection (CDI). We conducted a multicenter retrospective study to describe the incidence of CDI in children transplanted between January 2010 and June 2013. Nested case-control substudies, matched 1:1 by transplant type, institution, patient age, and time of year (quartile) of transplant, identified CDI risk factors. Cohorts included 1496 HCT and 1090 SOT recipients. Among HCT recipients, 355 CDI episodes were diagnosed in 265 recipients (18.2%). Nested case-control study identified prior history of CDI (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.5-4.7), proton pump inhibitors (PPIs; OR 2.1, 95% CI 1.3-3.4), and exposure to third- (OR 2.4, 95% CI 1.4-4.2) or fourth-generation (OR 2.1, 95% CI 1.2-3.7) cephalosporins as risk factors. Notably, fluoroquinolone exposure appeared protective (OR 0.6, 95% CI 0.3-0.9). Ninety-two episodes of CDI were diagnosed among 79 SOT recipients (7.3%), and exposure to PPIs (OR 2.4, 95% CI 1.1-5.4) and third-generation cephalosporin therapy (OR 3.9, 95% CI 1.4-10.5) were identified as risk factors. Strategies to decrease PPI use and changes in the class of prophylactic antibiotics may impact CDI incidence and warrant further study.
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Affiliation(s)
- Erick F Mayer
- Department of Pediatrics, Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York, USA
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Ronald H Dallas
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jose Ferrolino
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Li Tang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Yilun Sun
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Lara Danziger-Isakov
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Grant C Paulsen
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Brian T Fisher
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Surabhi B Vora
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Janet Englund
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - William J Steinbach
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Marian Michaels
- Department of Pediatrics & Surgery, Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael Green
- Department of Pediatrics & Surgery, Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nava Yeganeh
- Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Joy E Gibson
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Samuel R Dominguez
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Maribeth R Nicholson
- Department of Pediatrics, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel E Dulek
- Department of Pediatrics, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Monica I Ardura
- Department of Pediatrics & Host Defense Program, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sujatha Rajan
- Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York, USA
| | | | - Christy Beneri
- Department of Pediatric, Stony Brook School of Medicine, Stony Brook, New York, USA
| | - Betsy C Herold
- Department of Pediatrics, Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York, USA.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
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Karol SE, Sun Y, Tang L, Pui CH, Ferrolino J, Allison KJ, Cross SJ, Evans WE, Crews KR, Jeha S, Wolf J. Fluoroquinolone prophylaxis does not increase risk of neuropathy in children with acute lymphoblastic leukemia. Cancer Med 2020; 9:6550-6555. [PMID: 32710497 PMCID: PMC7520302 DOI: 10.1002/cam4.3249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/18/2020] [Accepted: 05/31/2020] [Indexed: 12/24/2022] Open
Abstract
Background Fluoroquinolone antibiotics are frequently utilized in pediatric oncology patients as prophylaxis or step‐down therapy following broad spectrum beta‐lactam therapy for febrile neutropenia. Concerns regarding neurotoxicity limit the use of these agents. No studies have evaluated the association between fluoroquinolone use and neurotoxicity in pediatric oncology patients receiving other neurotoxic agents such as vincristine. Methods An observational cohort study comprising patients aged 0‐18 at diagnosis enrolled on a prospective study for treatment of acute lymphoblastic leukemia (ALL) at a pediatric comprehensive cancer center between October 2007 and November 2018. Data for neuropathic pain and sensory or motor neuropathy were collected prospectively, and a Cox proportional hazards regression model was used to evaluate associations between administration of fluoroquinolone antibiotics during induction therapy and subsequent development of vincristine‐induced peripheral neurotoxicity (VIPN). Results A total of 598 participants were enrolled, including 338 (57%) who received fluoroquinolones during induction therapy; of these 470 (79%) were diagnosed with VIPN and 139 (23%) were diagnosed with high‐grade (Grade 3+) VIPN. On unadjusted analyses, and analyses adjusted for age and race, there was no evidence of an association between fluoroquinolone exposure and subsequent VIPN (hazard ratio [HR] 0.8, 95% CI 0.5‐1.04, P = .08) or high‐grade VIPN (HR 1.1, 95% CI 0.4‐2.2, P = .87). Conclusions The results of this observational study do not show an association between exposure to fluoroquinolone antibiotics during induction therapy for ALL and subsequent development of vincristine‐induced peripheral neuropathies, and suggest that a large increase in VIPN is unlikely.
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Affiliation(s)
- Seth E Karol
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yilun Sun
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Li Tang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jose Ferrolino
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kim J Allison
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Shane J Cross
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - William E Evans
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kristine R Crews
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sima Jeha
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joshua Wolf
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
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Haeusler GM, Phillips R, Slavin MA, Babl FE, De Abreu Lourenco R, Mechinaud F, Thursky KA. Re-evaluating and recalibrating predictors of bacterial infection in children with cancer and febrile neutropenia. EClinicalMedicine 2020; 23:100394. [PMID: 32637894 PMCID: PMC7329706 DOI: 10.1016/j.eclinm.2020.100394] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Numerous paediatric febrile neutropenia (FN) clinical decision rules (CDRs) have been derived. Validation studies show reduced performance in external settings. We evaluated the association between variables common across published FN CDRs and bacterial infection and recalibrated existing CDRs using these data. METHODS Prospective data from the Australian-PICNICC study which enrolled 858 FN episodes in children with cancer were used. Variables shown to be significant predictors of infection or adverse outcome in >1 CDR were analysed using multivariable logistic regression. Recalibration included re-evaluation of beta-coefficients (logistic model) or recursive-partition analysis (tree-based models). FINDINGS Twenty-five unique variables were identified across 17 FN CDRs. Fourteen were included in >1 CDR and 10 were analysed in our dataset. On univariate analysis, location, temperature, hypotension, rigors, severely unwell and decreasing platelets, white cell count, neutrophil count and monocyte count were significantly associated with bacterial infection. On multivariable analysis, decreasing platelets, increasing temperature and the appearance of being clinically unwell remained significantly associated. Five rules were recalibrated. Across all rules, recalibration increased the AUC-ROC and low-risk yield as compared to non-recalibrated data. For the SPOG-adverse event CDR, recalibration also increased sensitivity and specificity and external validation showed reproducibility. INTERPRETATION Degree of marrow suppression (low platelets), features of inflammation (temperature) and clinical judgement (severely unwell) have been consistently shown to predict infection in children with FN. Recalibration of existing CDRs is a novel way to improve diagnostic performance of CDRs and maintain relevance over time. FUNDING National Health and Medical Research Council Grant (APP1104527).
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- The Paediatric Integrated Cancer Service, Parkville, Victoria State Government, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Australia
- Murdoch Children's Research Institute, Parkville, Australia
- Corresponding author: Dr Gabrielle M. Haeusler, Department of Infectious Diseases, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Australia, 3000, P: +61 3 9656 5853 F: +61 3 9656 1185.
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, United Kingdom
| | - Monica A. Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute, Parkville, Australia
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Broadway, Australia
| | - Francoise Mechinaud
- Unité d'hématologie immunologie pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, France
| | - Karin A. Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
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Karol SE, Alexander TB, Budhraja A, Pounds SB, Canavera K, Wang L, Wolf J, Klco JM, Mead PE, Das Gupta S, Kim SY, Salem AH, Palenski T, Lacayo NJ, Pui CH, Opferman JT, Rubnitz JE. Venetoclax in combination with cytarabine with or without idarubicin in children with relapsed or refractory acute myeloid leukaemia: a phase 1, dose-escalation study. Lancet Oncol 2020; 21:551-560. [PMID: 32171069 PMCID: PMC7153631 DOI: 10.1016/s1470-2045(20)30060-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/16/2020] [Accepted: 01/16/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Outcomes for children with relapsed or refractory acute myeloid leukaemia remain poor. The BCL-2 inhibitor, venetoclax, has shown promising activity in combination with hypomethylating agents and low-dose cytarabine in older adults for whom chemotherapy is not suitable with newly diagnosed acute myeloid leukaemia. We aimed to determine the safety and explore the activity of venetoclax in combination with standard and high-dose chemotherapy in paediatric patients with relapsed or refractory acute myeloid leukaemia. METHODS We did a phase 1, dose-escalation study at three research hospitals in the USA. Eligible patients were aged 2-22 years with relapsed or refractory acute myeloid leukaemia or acute leukaemia of ambiguous lineage with adequate organ function and performance status. During dose escalation, participants received venetoclax orally once per day in continuous 28-day cycles at either 240 mg/m2 or 360 mg/m2, in combination with cytarabine received intravenously every 12 h at either 100 mg/m2 for 20 doses or 1000 mg/m2 for eight doses, with or without intravenous idarubicin (12 mg/m2) as a single dose, using a rolling-6 accrual strategy. The primary endpoint was the recommended phase 2 dose of venetoclax plus chemotherapy and the secondary endpoint was the proportion of patients treated at the recommended phase 2 dose who achieved complete remission or complete remission with incomplete haematological recovery. Analyses were done on patients who received combination therapy. The study is registered with ClinicalTrials.gov (NCT03194932) and is now enrolling to address secondary and exploratory objectives. FINDINGS Between July 1, 2017, and July 2, 2019, 38 patients were enrolled (aged 3-22 years; median 10 [IQR 7-13]), 36 of whom received combination therapy with dose escalation, with a median follow-up of 7·1 months (IQR 5·1-11·2). The recommended phase 2 dose of venetoclax was found to be 360 mg/m2 (maximum 600 mg) combined with cytarabine (1000 mg/m2 per dose for eight doses), with or without idarubicin (12 mg/m2 as a single dose). Overall responses were observed in 24 (69%) of the 35 patients who were evaluable after cycle 1. Among the 20 patients treated at the recommended phase 2 dose, 14 (70%, 95% CI 46-88) showed complete response with or without complete haematological recovery, and two (10%) showed partial response. The most common grade 3-4 adverse events were febrile neutropenia (22 [66%]), bloodstream infections (six [16%]), and invasive fungal infections (six [16%]). Treatment-related death occurred in one patient due to colitis and sepsis. INTERPRETATION The safety and activity of venetoclax plus chemotherapy in paediatric patients with heavily relapsed and refractory acute myeloid leukaemia suggests that this combination should be tested in newly diagnosed paediatric patients with high-risk acute myeloid leukaemia. FUNDING US National Institutes of Health, American Lebanese Syrian Associated Charities, AbbVie, and Gateway for Cancer Research.
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Affiliation(s)
- Seth E Karol
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Thomas B Alexander
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - Amit Budhraja
- Department of Cell and Molecular Biology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Stanley B Pounds
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Kristin Canavera
- Department of Psychology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Lei Wang
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Joshua Wolf
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Jeffery M Klco
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Paul E Mead
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Soumyasri Das Gupta
- Department of Cell and Molecular Biology, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Ahmed Hamed Salem
- AbbVie, North Chicago, IL, USA; Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | | | - Norman J Lacayo
- Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Ching-Hon Pui
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Joseph T Opferman
- Department of Cell and Molecular Biology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Jeffrey E Rubnitz
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA.
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Saito S, Yanagisawa R, Minami K, Uchida E, Watanabe T, Komori K, Kurata T, Nakamura T, Sakashita K. Prophylactic piperacillin administration in pediatric patients with solid tumors following different intensities of chemotherapy. Pediatr Int 2020; 62:158-168. [PMID: 31846519 DOI: 10.1111/ped.14103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 12/04/2019] [Accepted: 12/12/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Prophylactic antibiotics decrease mortality and morbidity in patients with hematological malignancies following intensive chemotherapy. However, the efficacy of prophylactic antibiotics for pediatric patients with solid tumors remains unclear. METHODS We retrospectively assessed 103 neutropenic periods from 26 patients with neuroblastoma or brain tumors following three different intensity chemotherapy regimens (05A3, A, and B). While piperacillin was intravenously administered as prophylaxis (PIPC prophylaxis group), the historical control group received no prophylaxis. As patients exhibited a variable degree of myelosuppression based on the intensity of the chemotherapy regimen, we separately evaluated the frequency and severity of febrile neutropenia (FN) in each regimen. RESULTS Following intensive chemotherapy, we observed a significantly lower frequency of FN in the PIPC prophylaxis group compared with the historical control group in both regimen 05A3 (20% vs 65%; P = 0.01) and regimen A (56% vs 93%; P = 0.02). We also observed a shorter duration of fever, lower maximum fever, and lower C-reactive protein levels in the PIPC prophylaxis group compared with the historical control group after regimens 05A3 and A. Conversely, the frequency and severity of FN were not different between the two groups after moderate-intensity chemotherapy (regimen B). However, a longitudinal routine surveillance study of Pseudomonas aeruginosa also indicated a reduction in the susceptibility to PIPC throughout the study period. CONCLUSIONS Although PIPC prophylaxis might provide an advantage for severe neutropenia in pediatric patients with solid tumors, there is concern regarding bacterial resistance to antibiotics. Therefore, further careful examination is necessary for adaptation.
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Affiliation(s)
- Shoji Saito
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan.,Life Science Research Center, Nagano Children's Hospital, Azumino, Japan.,Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryu Yanagisawa
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan.,Division of Blood Transfusion, Shinshu University Hospital, Matsumoto, Japan.,Center for Advanced Cell Therapy, Shinshu University Hospital, Matsumoto, Japan
| | - Kisei Minami
- Department of General Pediatrics, Nagano Children's Hospital, Azumino, Japan
| | - Eriko Uchida
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Tatsuo Watanabe
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Kazutoshi Komori
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Takashi Kurata
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Tomohiko Nakamura
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan
| | - Kazuo Sakashita
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan.,Life Science Research Center, Nagano Children's Hospital, Azumino, Japan
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Zhu Y, Yang R, Cai J, Yu J, Tang Y, Chen Y, Wang N, He H, Wu X, Cheng FWT, Sun L, He Y, Ju X, Tian X, Hu Q, Jin R, Pan K, Fang Y, Zhai X, Jiang H, Li CK. Septicemia after chemotherapy for childhood acute lymphoblastic leukemia in China: A multicenter study CCCG-ALL-2015. Cancer Med 2020; 9:2113-2121. [PMID: 31994344 PMCID: PMC7064088 DOI: 10.1002/cam4.2889] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/12/2020] [Accepted: 01/13/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Septicemia is an important cause of treatment-related mortality and treatment failure in pediatric acute lymphoblastic leukemia (ALL) in developing countries. A multicenter CCCG-ALL-2015 study was conducted in China and factors associated with septicemia and mortality were studied. METHODS Patients participated in CCCG-ALL-2015 study from January 2015 to December 2017 were included. Patients with documented septicemia were identified from the Data Center and additional data were collected. RESULTS A total of 4080 patients were recruited in the study and 527 patients with septicemia were identified (12.9%, 95% CI 11.9%-13.9%). The intermediate risk (IR)/high risk (HR) group had significantly higher incidence of septicemia as compared with low risk (LR) group, 17.1% vs 9.1% (OR 2.07, 95% CI 1.71-2.49, P < .001). Induction phase was the period with majority of septicemia episodes happened, 66.8% in LR and 56.1% in IR/HR groups. Gram-positive bacteria accounted for 54.1%, gram-negative bacteria 44.5%, and fungus 1.4% of positive cultures. Multidrug-resistant organisms were detected in 20.5% of all organisms. The mortality rate after septicemia was 3.4% (95% CI 1.9%-4.9%). Multiple logistic regression identified female gender, comorbid complications, and fungal infection as risk factors associated with mortality. Gram-negative septicemia was associated with higher mortality, 4.9% vs 1.4% (OR 0.28, 95% CI 0.09-0.88, P = .02). There was marked variation in the incidence of septicemia among the 18 centers, from 4.8% to 29.1%. CONCLUSION Overall the incidence and pattern of septicemia in this multicenter study in China was similar to the reports of western countries. The septicemia-related mortality rate was low. There was marked variation in the incidence of septicemia among the centers.
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Affiliation(s)
- Yiping Zhu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Department of Pediatric Hematology/Oncology, West China Second Hospital of Sichuan University, Chengdu, China
| | - Rong Yang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Department of Pediatric Hematology/Oncology, West China Second Hospital of Sichuan University, Chengdu, China
| | - Jiaoyang Cai
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiaotong University of School of Medicine, Shanghai, China
| | - Jie Yu
- Department of Hematology/Oncology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yanjing Tang
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiaotong University of School of Medicine, Shanghai, China
| | - Yumei Chen
- State Key Laboratory of Experimental Hematology and Division of Pediatric Blood Diseases Center, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Ningling Wang
- Department of Pediatrics, Anhui Medical University Second Affiliated Hospital, Hefei, China
| | - Hailong He
- Department of Hematology/Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Xuedong Wu
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Frankie W T Cheng
- Department of Paediatrics, Hong Kong Children's Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lirong Sun
- Department of Pediatrics, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yingyi He
- Department of Hematology/Oncology, Guangzhou Women and Children Health Care Center, Guangzhou, China
| | - Xiuli Ju
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Xin Tian
- Department of Hematology/Oncology, Kunming Children's Hospital, Kunming, China
| | - Qun Hu
- Department of Pediatric Hematology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Runming Jin
- Department of Pediatrics, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kaili Pan
- Department of Hematology/Oncology, Xi'an Northwest Women and Children Hospital, Xian, China
| | - Yongjun Fang
- Department of Hematology/Oncology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Xiaowen Zhai
- Department of Hematology Oncology, Children's hospital of Fudan University, Shanghai, China
| | - Hui Jiang
- Department of Hematology Oncology, Children's Hospital Affiliated to Shanghai Jiaotong University, Shanghai, China
| | - Chi-Kong Li
- Department of Paediatrics, Hong Kong Children's Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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48
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Haeusler GM, Thursky KA, Slavin MA, Babl FE, De Abreu Lourenco R, Allaway Z, Mechinaud F, Phillips R. Risk stratification in children with cancer and febrile neutropenia: A national, prospective, multicentre validation of nine clinical decision rules. EClinicalMedicine 2020; 18:100220. [PMID: 31993576 PMCID: PMC6978200 DOI: 10.1016/j.eclinm.2019.11.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/12/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Reduced intensity treatment of low-risk febrile neutropenia (FN) in children with cancer is safe and improves quality of life. Identifying children with low-risk FN using a validated risk stratification strategy is recommended. This study prospectively validated nine FN clinical decision rules (CDRs) designed to predict infection or adverse outcome. METHODS Data were collected on consecutive FN episodes in this multicentre, prospective validation study. The reproducibility and discriminatory ability of each CDR in the validation cohort was compared to the derivation dataset and details of missed outcomes were reported. FINDINGS There were 858 FN episodes in 462 patients from eight hospitals included. Bacteraemia occurred in 111 (12·9%) and a non-bacteraemia microbiological documented infection in 185 (21·6%). Eight CDRs exhibited reproducibility and sensitivity ranged from 64% to 96%. Rules that had >85% sensitivity in predicting outcomes classified few patients (<20%) as low risk. For three CDRs predicting a composite outcome of any bacterial or viral infection, the sensitivity and discriminatory ability improved for prediction of bacterial infection alone. Across all CDRs designed to be implemented at FN presentation, the sensitivity improved at day 2 assessment. INTERPRETATION While reproducibility was observed in eight out of the nine CDRs, no rule perfectly differentiated between children with FN at high or low risk of infection. This is in keeping with other validation studies and highlights the need for additional safeguards against missed infections or adverse outcomes before implementation can be considered.
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Affiliation(s)
- Gabrielle M. Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- The Victorian Paediatric Integrated Cancer Service, Victoria State Government, Melbourne, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
- Corresponding author at: Department of Infectious Diseases, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne 3000, Australia.
| | - Karin A. Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Monica A. Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Franz E. Babl
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT)
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Zoe Allaway
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Francoise Mechinaud
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Unité d'hématologie immunologie pédiatrique, Hopital Robert Debré, APHP Nord Université de Paris, France
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, United Kingdom
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49
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Kurtti A, Fritz K, Elofson-Disney K, Benefield R. Obesity is not strongly associated with increased risk for febrile neutropenia during levofloxacin prophylaxis in patients with hematological malignancies receiving intermediate-risk myelosuppressive chemotherapy. J Oncol Pharm Pract 2019; 26:1301-1305. [PMID: 31810423 DOI: 10.1177/1078155219890403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Levofloxacin given at a standard dose of 500 mg daily is recommended for antibacterial prophylaxis in patients receiving myelosuppressive chemotherapy. Obese patients have been shown to exhibit enhanced clearance of levofloxacin and may be at risk for prophylactic failure. This single center, retrospective cohort study from June 2014 to May 2017 evaluated adult patients with estimated creatinine clearance ≥50 mL/min receiving their first cycle of a National Comprehensive Cancer Network defined intermediate-risk regimen. Primary endpoint was incidence of febrile neutropenia. Secondary endpoints included 30-day mortality and the correlation between estimated levofloxacin area under the concentration-time curve and rates of febrile neutropenia. Febrile neutropenia occurred in 26 patients: 12 (35.3%) obese and 14 (21.9%) non-obese (P = 0.16). Six (23.1%) of these patients required intensive care, but there were no deaths within 30 days of a febrile neutropenia event. Estimated creatinine clearance was similar between obese and non-obese patients (median 97.5 vs. 91.8 mL/min, P = 0.39), as was estimated levofloxacin area under the concentration-time curve (median 85.6 vs. 90.8 mg×h/L, P = 0.39). There were no significant associations between body weight-related variables - total body weight (median 83.4 vs. 80.6 kg, P = 0.51), body mass index (mean 29.6 vs. 26.8 kg/m2, P = 0.35), or body surface area (1.98 vs. 1.99 m2, P = 0.68) - and febrile neutropenia in this cohort of patients with similar renal function. Obesity should not be a justification for more aggressive levofloxacin dosing schemes when used for febrile neutropenia prophylaxis.
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Affiliation(s)
- Amanda Kurtti
- Department of Pharmacy, Huntsman Cancer Institute, Salt Lake City, USA
| | - Kelly Fritz
- Department of Pharmacy, Huntsman Cancer Institute, Salt Lake City, USA
| | - Kathryn Elofson-Disney
- Department of Pharmacy, Huntsman Cancer Institute, Salt Lake City, USA.,Department of Pharmacy, University of Utah Health, Salt Lake City, USA
| | - Russell Benefield
- Department of Pharmacy, University of Utah Health, Salt Lake City, USA.,Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, USA
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50
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Hakim H, Dallas R, Wolf J, Tang L, Schultz-Cherry S, Darling V, Johnson C, Karlsson EA, Chang TC, Jeha S, Pui CH, Sun Y, Pounds S, Hayden RT, Tuomanen E, Rosch JW. Gut Microbiome Composition Predicts Infection Risk During Chemotherapy in Children With Acute Lymphoblastic Leukemia. Clin Infect Dis 2019. [PMID: 29518185 DOI: 10.1093/cid/ciy153] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Myelosuppression-related infections remain important causes of morbidity and mortality in children with acute lymphoblastic leukemia (ALL). Methods By analyzing fecal samples collected at diagnosis and after each of the initial 3 phases of chemotherapy, we evaluated the role of gut microbiota in predicting infections in 199 children with newly diagnosed ALL. The bacterial 16S rRNA gene was analyzed by high-depth sequencing to determine the diversity and composition of the microbiome. Results After the induction and reinduction I phases of chemotherapy, microbial diversity decreased significantly relative to the prechemotherapy value. After chemotherapy, the relative abundance of certain bacterial taxa (eg, Bacteroidetes) decreased significantly, whereas that of other taxa (eg, Clostridiaceae and Streptococcaceae) increased. A baseline gut microbiome characterized by Proteobacteria predicted febrile neutropenia. Adjusting for the chemotherapy phase and ALL risk level, Enterococcaceae dominance (relative abundance ≥30%) predicted significantly greater risk of subsequent febrile neutropenia and diarrheal illness, whereas Streptococcaceae dominance predicted significantly greater risk of subsequent diarrheal illness. Conclusions In children undergoing therapy for newly diagnosed ALL, the relative abundance of Proteobacteria before chemotherapy initiation predicts development of febrile neutropenia, and domination of the gut microbiota by Enterococcaceae or Streptococcaceae at any time during chemotherapy predicts infection in subsequent phases of chemotherapy. Clinical Trial Registration NCT00549848.
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Affiliation(s)
- Hana Hakim
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Ronald Dallas
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Joshua Wolf
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Li Tang
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Stacey Schultz-Cherry
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Victoria Darling
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Cydney Johnson
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Erik A Karlsson
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Ti-Cheng Chang
- Department of Computational Biology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Sima Jeha
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Ching-Hon Pui
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Yilun Sun
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Stanley Pounds
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Randall T Hayden
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Elaine Tuomanen
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Jason W Rosch
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
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