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Kirolos N, Tang K, Abbott LS. Does age play a role in fever and neutropenia events and complications: A comparison of adolescents versus younger children with cancer at a tertiary care pediatric hospital, a pilot project. Cancer Rep (Hoboken) 2022; 6:e1767. [PMID: 36494902 PMCID: PMC10075292 DOI: 10.1002/cnr2.1767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/19/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Adolescents and young adults with cancer (AYA) are a complex group of patients. The development of fever and neutropenia (FN) is a potentially lethal complication of chemotherapy. Risk stratification of patients with FN has become increasingly valuable allowing for early intervention and to guide treatment type and duration appropriately. There are risk stratification guidelines that exist, but most are validated in young children with cancer (YCWC). AYA are frequently shown to have more numerous and severe side effects from chemotherapy. AIMS This study aimed to identify whether age contributes to the incidence and severity of FN. METHODS AND RESULTS Patients diagnosed with a malignancy in a 5-year period at our institution were included from ages 0-18 years. We reviewed details of their FN events, including duration of hospital admission, source (bacterial/fungal), PICU admission and duration, positive blood cultures and mortality. Adolescents with cancer (AWC) had a trend of being 1.56 times more likely to have FN events (CI 95% 0.936-2.622, p = 0.087). Assessment of the duration of PICU stay showed that AWC were 4.9 times more likely to have longer admissions (CI 95% 0.998-24.067, p = 0.050). There was no significant difference between the two groups in the rate of PICU admission, positive cultures, identification of a bacterial or fungal source, hospital admission duration or mortality from FN. CONCLUSION This study demonstrated a trend towards AWC being more likely to develop FN events. When such events occur in this group, the severity of them may be heightened as evidenced by longer duration of PICU admission.
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Affiliation(s)
- Nardin Kirolos
- Division of Hematology/Oncology Children's Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Ken Tang
- CHEO Research Institute Children's Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Lesleigh S. Abbott
- Division of Hematology/Oncology Children's Hospital of Eastern Ontario Ottawa Ontario Canada
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Dessie AS, Lanning M, Nichols T, Delgado EM, Hart LS, Agrawal AK. Patient Outcomes With Febrile Neutropenia Based on Time to Antibiotics in the Emergency Department. Pediatr Emerg Care 2022; 38:e259-e263. [PMID: 32941363 DOI: 10.1097/pec.0000000000002241] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Although bacteremia in pediatric oncology patients with febrile neutropenia (FN) is not uncommon, sepsis and mortality are rare. Because of the lack of clinically meaningful decision tools to identify high-risk patients with bacteremia, time to antibiotic administration (TTA) is increasingly considered an important quality and safety measure in the emergency department. Because little evidence exists suggesting that this benchmark is beneficial, we sought to determine whether TTA of 60 minutes or less is associated with improved outcomes. METHODS We retrospectively reviewed patients presenting to a pediatric emergency department with FN from November 2013 to June 2016. Clinical outcomes including mortality, pediatric intensive care unit admission, imaging, fluid resuscitation of 40 mL/kg or greater in the first 24 hours, and length of stay were compared between TTA of 60 minutes or less and more than 60 minutes. RESULTS One hundred seventy-nine episodes of FN were analyzed. The median TTA was 76 minutes (interquartile range, 58-105). The incidence of bacteremia was higher in patients with TTA of more than 60 minutes (12% vs 2%, P = 0.04), but without impact on mortality, pediatric intensive care unit admission, fluid resuscitation, or median length of stay. The median TTA was not different for those who were and were not bacteremic (91 vs 73 minutes, P = 0.11). CONCLUSIONS Time to antibiotic administration of more than 60 minutes did not increase mortality in pediatric oncology patients with FN. Our study adds to the existing literature that TTA of 60 minutes or less does not seem to improve outcomes in pediatric FN. Further larger studies are required to confirm these findings and determine which features predispose pediatric FN patients to morbidity and mortality.
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Affiliation(s)
| | - Miranda Lanning
- New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Tristan Nichols
- Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | | | | | - Anurag K Agrawal
- Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, CA
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3
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Willmer D, Zöllner SK, Schaumburg F, Jürgens H, Lehrnbecher T, Groll AH. Infectious Morbidity in Pediatric Patients Receiving Neoadjuvant Chemotherapy for Sarcoma. Cancers (Basel) 2021; 13:cancers13091990. [PMID: 33919049 PMCID: PMC8122626 DOI: 10.3390/cancers13091990] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 01/13/2023] Open
Abstract
Simple Summary Infections are an important cause of morbidity and mortality in childhood cancer treatment. The aim of our retrospective study was to assess the infectious burden in pediatric sarcoma patients during neoadjuvant chemotherapy administered according to the EWING 2008, CWS SoTiSaR and EURAMOS clinical trial or registry. Our analyses indicate a substantial infectious morbidity in this group of patients, with 58.8% experiencing at least one episode of febrile neutropenia (FN) and 20.6% at least one microbiologically documented infection (MDI). We also identified parameters that impact on the occurrence of FN and MDIs, including treatment protocol, patient age, and mucositis. These findings may contribute to a better risk stratification for prevention and management of FN and infections as well as for maintaining quality of life, cost control, and optimum outcomes of anticancer treatment. Abstract The purpose of this retrospective, single-center cohort study was to assess the infectious burden in pediatric sarcoma patients during neoadjuvant chemotherapy. The review included all patients with a new diagnosis of Ewing sarcoma, osteosarcoma or soft tissue sarcoma between September 2009 and December 2018 who were enrolled in the EWING 2008, CWS SoTiSaR and EURAMOS clinical trial or registry. Primary endpoints were the occurrence of febrile neutropenia (FN) and microbiologically documented infection (MDI). Parameters with a potential impact on FN and MDI were also analyzed. A total of 170 sarcoma patients (median age: 13 years, range: 0–21; 96 m/74 f) received 948 chemotherapy courses (median: 6; range: 2–8). Of these patients, 58.8% had ≥1 FN episode and 20.6% ≥ 1 MDI. FN occurred in 272/948 courses (28.7%) with fever of unknown origin (FUO) in 231 courses and 45 MDI and 19 clinically documented infections (CDI) occurring in a total of 57 courses. Patients enrolled in EWING 2008 had significantly more FN (p < 0.001), infections (p = 0.02) and MDI (p = 0.035). No infection-related deaths were observed. Younger age, tumor type and localization, and higher median and maximum mucositis grades were significantly associated with higher numbers of FN (p < 0.001), and younger age (p = 0.024) and higher median mucositis grade (p = 0.017) with MDI. The study shows substantial infectious morbidity in sarcoma patients during neoadjuvant chemotherapy treatment and opportunities to improve prevention and management.
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Affiliation(s)
- Denise Willmer
- Infectious Disease Research Program, Center for Bone Marrow Transplantation, Department of Pediatric Hematology/Oncology, University Children’s Hospital Münster, 48149 Münster, Germany; (D.W.); (S.K.Z.); (H.J.)
| | - Stefan K. Zöllner
- Infectious Disease Research Program, Center for Bone Marrow Transplantation, Department of Pediatric Hematology/Oncology, University Children’s Hospital Münster, 48149 Münster, Germany; (D.W.); (S.K.Z.); (H.J.)
- Department of Pediatric Oncology & Hematology, Pediatrics III, University Hospital of Essen, 45147 Essen, Germany
| | - Frieder Schaumburg
- Institute of Medical Microbiology, University Hospital Münster, 48149 Münster, Germany;
| | - Heribert Jürgens
- Infectious Disease Research Program, Center for Bone Marrow Transplantation, Department of Pediatric Hematology/Oncology, University Children’s Hospital Münster, 48149 Münster, Germany; (D.W.); (S.K.Z.); (H.J.)
| | - Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, 60590 Frankfurt am Main, Germany;
| | - Andreas H. Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation, Department of Pediatric Hematology/Oncology, University Children’s Hospital Münster, 48149 Münster, Germany; (D.W.); (S.K.Z.); (H.J.)
- Correspondence: ; Tel.: +49-251-834-7742; Fax: +49-251-834-7828
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Clinical characteristics and evolution of pediatric patients with acute leukemia and SARS-COV2 virus infection in a third level hospital in Mexico. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2021. [PMCID: PMC7686788 DOI: 10.1016/j.phoj.2020.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Introduction Reports have revealed that people susceptible to severe forms of COVID-19 are older adults with comorbidities; However, the pediatric population has also been affected, considering children with underlying conditions such as onco-hematological conditions to be high risk. We present a cases series in a third level hospital. Material and methods We conducted a retrospective study in children under the age of 16 years with a diagnosis of acute leukemia and infection with the SARS-CoV2 virus. Descriptive statistics with means and percentages were used. To show differences between the groups, Chi-square test, Student t test and Mann-Whitney U test were used depending on the type of variable and its distribution. Results SARS-CoV2 virus infection was confirmed in 15 children diagnosed with acute leukemia, at different stages of treatment. The mean age was 7.5 years, 8 male and 7 female, 11 of them diagnosed with acute B-cell lymphoblastic leukemia, one with acute T-cell lymphoblastic leukemia and 3 with acute myeloid leukemia. The mean days of hospital stay at the diagnosis of COVID-19 was 22. Thirteen of the children had fever and neutropenia. 7 patients died. There was a statistically significant correlation with the outcome in patients who presented a prolongation of aPTT, an increase in D-dimer, an increase in liver enzymes and severe respiratory distress with the need for mechanical ventilation. Conclusion The risk of death in children with leukemia and COVID-19 was associated with prolonged aPTT, increased D-dimer, increased liver enzymes, respiratory distress, and the need for mechanical ventilation.
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Flores V, Miranda R, Merino L, González C, Serrano C, Solano M, Herrera J, González P, Ruiz G, Saldaña R, Cárdenas A, Chávez-Aguilar LA. SARS-CoV-2 infection in children with febrile neutropenia. Ann Hematol 2020; 99:1941-1942. [PMID: 32529285 PMCID: PMC7289627 DOI: 10.1007/s00277-020-04115-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/01/2020] [Indexed: 01/30/2023]
Affiliation(s)
- Victoria Flores
- Department of Pediatric Hematology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Raquel Miranda
- Department of Pediatric Hematology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Laura Merino
- Department of Pediatric Hematology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Carmen González
- Department of Pediatric Hematology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Cristina Serrano
- Department of Pediatric Hematology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Moises Solano
- Department of Pediatric Hematology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Jessica Herrera
- Department of Pediatric Hematology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Paulina González
- Department of Pediatric Hematology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Genesis Ruiz
- Department of Pediatric Hematology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Ricardo Saldaña
- Department of Pediatric Hematology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Ahtziri Cárdenas
- Department of Pediatric Hematology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Lénica A Chávez-Aguilar
- Department of Pediatric Hematology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico.
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AlAzmi A, Jastaniah W, AlDabbagh M, Elimam N. A clinical approach to non-neutropenic fever in children with cancer. J Oncol Pharm Pract 2020; 27:560-569. [PMID: 32476589 DOI: 10.1177/1078155220925161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There are a limited number of studies that address non-neutropenic fever episodes in children with cancer, and no standard approach exists. METHOD We opt to retrospectively analyze the efficacy of the current clinical approach for management of non-neutropenic fever episodes and the associated risk factors among children with cancer at the Princess Noorah Oncology Center from May 2016 through December 2017. RESULTS A total of 480 non-neutropenic fever episodes were identified in 131 children, of which 62 episodes were triaged as high-risk non-neutropenic fever and 418 as low-risk non-neutropenic fever. Of those 480 non-neutropenic fever, 361 episodes (75.2%) were associated with the presence of central venous catheters. The overall failure rate of ceftriaxone mono-therapy was observed in 75.6% (11.7% in high-risk non-neutropenic fever with a mean C-reactive protein level of 21.1 (±23.2) mmol/L and 63.9% in low-risk non-neutropenic fever with a mean C-reactive protein level of 17.6 (±53.9) mmol/L). The overall bacteremia rate was 14.4%. The type of organisms isolated was mainly high-risk organisms in 59 non-neutropenic fever episodes (85.5%), OR 1.78 (95% CI: 0.45-7.04) p = 0.41. Of note, all bacteremia were associated with the presence of central venous catheter (100%). Of all the examined risk factors of outpatient treatment failure in low-risk non-neutropenic fever, only prolonged fever of more than three days were significantly associated with bacteremia OR 8.107 [95% CI: 1.744-37.691], p = 0.008. Noteworthy is that almost 43% of non-neutropenic fever episodes were associated with respiratory symptoms. This study provides a baseline for future prospective research assessing the pattern of non-neutropenic fever by focusing on associated risk factors.
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Affiliation(s)
- Aeshah AlAzmi
- Department of Pharmaceutical Care Clinical Services, King Abdulaziz Medical City, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Faculty of Medicine, Jeddah, Saudi Arabia
- Department of Pediatrics, Oncology/Hematology/BMT, Princes Noorah Oncology Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Wasil Jastaniah
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Faculty of Medicine, Jeddah, Saudi Arabia
- Department of Pediatrics, Oncology/Hematology/BMT, Princes Noorah Oncology Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
- Department of Pediatrics, Faculty of Medicine, Umm AlQura University, Makkah, Saudi Arabia
| | - Mona AlDabbagh
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Faculty of Medicine, Jeddah, Saudi Arabia
- Department of Pediatrics, Division of Infectious diseases, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Naglla Elimam
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Faculty of Medicine, Jeddah, Saudi Arabia
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Zermatten MG, Koenig C, von Allmen A, Agyeman P, Ammann RA. Episodes of fever in neutropenia in pediatric patients with cancer in Bern, Switzerland, 1993-2012. Sci Data 2019; 6:180304. [PMID: 30644854 PMCID: PMC6335615 DOI: 10.1038/sdata.2018.304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/26/2018] [Indexed: 11/09/2022] Open
Abstract
Fever in neutropenia (FN) is the most frequent potentially life threatening complication of chemotherapy for cancer. Prediction of the risk to develop complications, integrated into clinical decision rules, would allow for risk-stratified treatment of FN. This retrospective, single center cohort study in pediatric patients diagnosed with cancer before 17 years, covered two decades, 1993 to 2012. In total, 703 FN episodes in 291 patients with chemotherapy (maximum per patient, 9) were reported here. Twenty-nine characteristics of FN were collected: 6 were patient- and cancer-related, 8 were characteristics of history, 8 of clinical examination, and 7 laboratory results in peripheral blood, all known at FN diagnosis. In total 28 FN outcomes were assessed: 8 described treatment of FN, 6 described microbiologically defined infections (MDI), 4 clinically defined infections, 4 were additional clinical composite outcomes, and 6 outcomes were related to discharge. These data can mainly be used to study FN characteristics and their association with outcomes over time and between centers, and for derivation and external validation of clinical decision rules.
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Affiliation(s)
- Maxime G. Zermatten
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Philipp Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roland A. Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Wagner S, Brack EK, Stutz-Grunder E, Agyeman P, Leibundgut K, Teuffel O, Ammann RA. The influence of different fever definitions on diagnostics and treatment after diagnosis of fever in chemotherapy-induced neutropenia in children with cancer. PLoS One 2018; 13:e0193227. [PMID: 29462193 PMCID: PMC5819814 DOI: 10.1371/journal.pone.0193227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 02/07/2018] [Indexed: 11/18/2022] Open
Abstract
Background There is no evidence-based definition of the temperature limit defining fever (TLDF) in children with neutropenia. Lowering the TLDF is known to increase the number of episodes of fever in neutropenia (FN). This study aimed to investigate the influence of a lower versus standard TLDF on diagnostics and therapy. Methods In a single pediatric cancer center using a high standard TLDF (39°C tympanic-temperature) patients were observed prospectively (NCT01683370). The effect of applying lower TLDFs (range 37.5°C to 38.9°C) versus 39.0°C on these measures was simulated in silicon. Results In reality, 45 FN episodes were diagnosed. Of 3391 temperatures measured, 193 were ≥39.0°C, and 937 ≥38.0°C. For persisting fever ≥24 hours, additional blood cultures were taken in 31 (69%) episodes in reality. This number decreased to 22 (49%) when applying 39.0°C, and increased to 33 for 38.0°C (73%; plus 11 episodes; plus 24%). For persisting fever ≥48 hours, i.v.-antibiotics were escalated in 25 (56%) episodes. This number decreased to 15 (33%) when applying 39.0°C, and increased to 26 for 38.0°C (58%; plus 11 episodes; plus 24%). For persisting fever ≥120 hours, i.v.-antifungals were added in 4 (9%) episodes. This number increased to 6 (13%) by virtually applying 39.0°C, and to 11 for 38.0°C (24%; plus 5 episodes; plus 11%). The median length of stay was 5.7 days (range, 0.8 to 43.4). In 43 episodes with hospital discharge beyond 24 hours, applying 38.0°C led to discharge delay by ≥12 hours in 24 episodes (56%; 95% CI, 40 to 71), with a median delay of 13 hours, and a cumulative delay of 68 days. Conclusion Applying a low versus standard TLDF led to relevant increases of diagnostics, antimicrobial therapy, and length of stay. The differences between management in reality versus simply applying 39.0° as TLDF reflect the important impact of clinical assessment.
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Affiliation(s)
- Stéphanie Wagner
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eva K. Brack
- Department of Infectious Disease and Cancer Research, Children´s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Eveline Stutz-Grunder
- Department of Pediatric Oncology, Children´s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Philipp Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kurt Leibundgut
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Oliver Teuffel
- Division of Oncology, Medical Services of the Statutory Health Insurance Baden-Württemberg, Tübingen, Germany
| | - Roland A. Ammann
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
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Af Sandeberg M, Johansson E, Wettergren L, Björk O, Hertting O, Nilsson A. Antibiotic use during infectious episodes in the first 6 months of anticancer treatment-A Swedish cohort study of children aged 7-16 years. Pediatr Blood Cancer 2017; 64. [PMID: 28074531 DOI: 10.1002/pbc.26397] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 11/11/2016] [Accepted: 11/14/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND Children undergoing cancer therapy are at risk for infectious complications that require hospitalization and antimicrobial therapy. Host factors such as age and underlying disease may predict the risk of severe infections in these children. To describe the increased morbidity due to infections in children with cancer, we characterized the antibiotic use during the infectious complications in a national cohort of children 7-16 years of age with cancer. PROCEDURE Data on infectious complications were prospectively collected from the medical records of all newly diagnosed children with cancer, aged 7-16 years, in Sweden between 2004 and 2006. An episode of infection was defined as a period of time when oral or intravenous antimicrobial treatment was prescribed because of symptoms of infection. RESULTS A total of 230 infectious episodes occurred in 80 of the 101 patients. Pathogens were isolated in 15% of the blood cultures that showed a predominance of Gram-positive bacteria. Intravenous broad-spectrum antibiotics with cephalosporins and carbapenems were mostly used as single drugs but also in combination with aminoglycosides and glycopeptide. The median treatment length varied between 6 and 11 days depending on cancer diagnosis. CONCLUSION Our data demonstrate that infectious complications contribute significantly to morbidity in children with cancer aged 7-16 years. At the time of this survey, antibiotic prescription patterns varied and cephalosporins and carbapenems were mostly used. With increasing antibiotic resistance, a more stringent antibiotic stewardship with less use of cephalosporins and carbapenems should be encouraged for children with cancer. Data on prescription patterns should be incorporated as a quality measurement in pediatric cancer care.
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Affiliation(s)
- M Af Sandeberg
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Hematology and Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - E Johansson
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - L Wettergren
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden
| | - O Björk
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Astrid Lindgren Children's Hospital, Karolinska Institutet, Stockholm, Sweden
| | - O Hertting
- Pediatric Infectious Disease Unit, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - A Nilsson
- Department of Pediatric Hematology and Oncology, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Childhood Cancer Research Unit, Astrid Lindgren Children's Hospital, Karolinska Institutet, Stockholm, Sweden
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10
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Zhou Y, Cui Y, Wang H, Wang F, Lu C, Shen Y. Developing a tool for nurses to assess risk of infection in pediatric oncology patients in China: a modified Delphi study. J Biomed Res 2016; 30:386-392. [PMID: 27845302 PMCID: PMC5044711 DOI: 10.7555/jbr.30.20160014] [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: 01/28/2016] [Revised: 02/24/2016] [Accepted: 05/24/2016] [Indexed: 11/23/2022] Open
Abstract
Infections are identified as the most common preventable cause of death in pediatric oncology patients. Assessing and stratifying risk of infections are essential to prevent infection in these patients. To date, no tool can fulfill this demand in China. This study aimed to develop a nursing work-based and Chinese-specific tool for pediatric nurses to assess risk of infection in oncology patients. This research was a modified Delphi study. Based on a literature review, a 37-item questionnaire rating on a 0–5 scale was developed. Twenty-four experts from 8 hospitals in 6 provinces of China were consulted for three rounds. Consensus for each item in the first round was defined as: the rating mean was > 3 and the coefficient of variation (CV) was < 0.5. Consensus for each item in the second round was defined as CV < 0.3. Consensus among experts was defined as: P value of Kendall's coefficient of concordance (W) < 0.05. After three rounds of consultation, a two-part tool was developed: the Immune Status Scale (ISS) and the Checklist of Risk Factors of Infection (CRFI). There were 5 items in the ISS and 14 in the CRFI. Based on the ISS score, nurses could stratify children into the low-risk and high-risk groups. For high-risk children, nurses should screen risk factors of infection every day by the CRFI, and twice weekly for low-risk children. Further study is needed to verify this tool's efficacy.
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Affiliation(s)
- Yufeng Zhou
- Department of Basic and Community Nursing, School of Nursing, Nanjing Medical University, Nanjing, JIangsu 211166, China
| | - Yan Cui
- Department of Basic and Community Nursing, School of Nursing, Nanjing Medical University, Nanjing, JIangsu 211166, China;
| | - Hong Wang
- Department of Respiratory, The First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu 210029, China;
| | - Fang Wang
- Department of Paediatric, The First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Chao Lu
- Department of Paediatric, The First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Yan Shen
- Department of Paediatric, The First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu 210029, China
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Simon A, Furtwängler R, Graf N, Laws HJ, Voigt S, Piening B, Geffers C, Agyeman P, Ammann RA. Surveillance of bloodstream infections in pediatric cancer centers - what have we learned and how do we move on? GMS HYGIENE AND INFECTION CONTROL 2016; 11:Doc11. [PMID: 27274442 PMCID: PMC4886351 DOI: 10.3205/dgkh000271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pediatric patients receiving conventional chemotherapy for malignant disease face an increased risk of bloodstream infection (BSI). Since BSI may represent an acute life-threatening event in patients with profound immunosuppression, and show further negative impact on quality of life and anticancer treatment, the prevention of BSI is of paramount importance to improve and guarantee patients' safety during intensive treatment. The great majority of all pediatric cancer patients (about 85%) have a long-term central venous access catheter in use (type Broviac or Port; CVAD). Referring to the current surveillance definitions a significant proportion of all BSI in pediatric patients with febrile neutropenia is categorized as CVAD-associated BSI. This state of the art review summarizes the epidemiology and the distinct pathogen profile of BSI in pediatric cancer patients from the perspective of infection surveillance. Problems in executing the current surveillance definition in this patient population are discussed and a new concept for the surveillance of BSI in pediatric cancer patients is outlined.
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Affiliation(s)
- Arne Simon
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Rhoikos Furtwängler
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Norbert Graf
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hans Jürgen Laws
- Klinik für Pädiatrische Onkologie, Hämatologie und Immunologie, Universitätskinderklinik, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Sebastian Voigt
- Klinik für Pädiatrie m. S. Onkologie / Hämatologie / Stammzelltransplantation, Charité – Universitätsmedizin Berlin, Germany
| | - Brar Piening
- Institut für Hygiene und Umweltmedizin, Charité – Universitätsmedizin Berlin, Germany
| | - Christine Geffers
- Institut für Hygiene und Umweltmedizin, Charité – Universitätsmedizin Berlin, Germany
| | - Philipp Agyeman
- Pädiatrische Infektiologie und Pädiatrische Hämatologie-Onkologie, Universitätsklinik für Kinderheilkunde, Inselspital, Bern, Switzerland
| | - Roland A. Ammann
- Pädiatrische Infektiologie und Pädiatrische Hämatologie-Onkologie, Universitätsklinik für Kinderheilkunde, Inselspital, Bern, Switzerland
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Jain R, Trehan A, Mishra B, Singh R, Saud B, Bansal D. Cytomegalovirus disease in children with acute lymphoblastic leukemia. Pediatr Hematol Oncol 2016; 33:239-47. [PMID: 27285991 DOI: 10.3109/08880018.2016.1173147] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Viral infections are an underrecognized problem in children on standard chemotherapy for acute lymphoblastic leukemia (ALL). In countries with high baseline seroprevalence of cytomegalovirus (CMV) such as India, it may be an important pathogen leading to fever, end-organ damage, and cytopenia. Data regarding the incidence and manifestations of CMV disease in pediatric ALL patients are scanty. The authors prospectively assessed all children on chemotherapy for ALL with prolonged febrile neutropenia (FN) for CMV disease over a 3-year period. Children with end-organ damage, including pneumonia, retinitis, and colitis, were also evaluated. Quantitative and qualitative polymerase chain reaction (PCR) from blood, body fluids, or tissue was done along with ophthalmologic evaluation. CMV disease was detected in 10% of the children with prolonged FN. In addition, other children were identified due to end-organ damage, lung and eye being the common organs of involvement. Time of CMV reactivation was essentially during nonintense phase of chemotherapy. Lymphopenia was present in most children, and prolonged lymphopenia was associated with relapse of CMV infection after therapy. The authors conclude that CMV is an important pathogen in children on standard chemotherapy for ALL. It has a good outcome with early detection and directed therapy. Parenteral ganciclovir is needed for a period of 14-21 days to prevent recurrence.
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Affiliation(s)
- Richa Jain
- a Division of Pediatric Hematology and Oncology, Department of Pediatrics , Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research , Chandigarh , India
| | - Amita Trehan
- a Division of Pediatric Hematology and Oncology, Department of Pediatrics , Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research , Chandigarh , India
| | - Baijyantimala Mishra
- b Department of Virology , Postgraduate Institute of Medical Education and Research , Chandigarh , India
| | - Ramandeep Singh
- c Department of Ophthalmology , Postgraduate Institute of Medical Education and Research , Chandigarh , India
| | - Bhuvan Saud
- b Department of Virology , Postgraduate Institute of Medical Education and Research , Chandigarh , India
| | - Deepak Bansal
- a Division of Pediatric Hematology and Oncology, Department of Pediatrics , Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research , Chandigarh , India
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Green AL, Yi J, Bezler N, Pikman Y, Tubman VN, Obeng EA, O'Neil T, Mersereau R, Morrissey L, Billett AL. A Prospective Cohort Quality Improvement Study to Reduce the Time to Antibiotics for New Fever in Neutropenic Pediatric Oncology Inpatients. Pediatr Blood Cancer 2016; 63:112-7. [PMID: 26292080 DOI: 10.1002/pbc.25712] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 07/15/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fever and neutropenia (F&N) is a pediatric oncology emergency due to the risk of disseminated infection. Quality improvement (QI) efforts to improve time to antibiotics for F&N in the emergency department have been documented, but the issue has not been studied in the established inpatient setting. PROCEDURE We undertook a prospective cohort QI study to decrease time to antibiotics for neutropenic pediatric oncology inpatients with new fever to <60 min. Our key intervention was discussion of a plan in case of new fever, including antibiotic(s) to be started, for each patient on rounds. Timing for each step in the process, from fever identification to antibiotic administration, was measured through the electronic medical record for each fever event. RESULTS The median time to antibiotics during the 3-three month intervention study period was 76.0 min, although the distribution was skewed due to several long outliers (mean 142.5, interquartile range 51-206, range 47-593 min). Time to antibiotics was significantly shorter when a fever contingency plan was documented in the most recent note than not (mean 102 vs. 254 min, P = 0.039). Over the total 2.75 year data-collection period, the quarterly percentage of patients receiving antibiotics within 60 min has improved from 35 to 65, whereas quarterly mean time to antibiotics has improved from 99 to 50 min. CONCLUSIONS Daily discussion of a fever contingency plan appears effective in decreasing the time to antibiotics for neutropenic pediatric oncology inpatients with new fever, likely by circumventing the need for multi-level discussion of the antibiotic plan when fever is identified.
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Affiliation(s)
- Adam L Green
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Joanna Yi
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Natalie Bezler
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Yana Pikman
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Venée N Tubman
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Esther A Obeng
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Teresa O'Neil
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Robert Mersereau
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Lisa Morrissey
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Amy L Billett
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
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14
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Management of fever and neutropenia in paediatric cancer patients: room for improvement? Curr Opin Infect Dis 2015; 28:532-8. [PMID: 26381997 DOI: 10.1097/qco.0000000000000208] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Fever and neutropenia is the most common complication in the treatment of childhood cancer. This review will summarize recent publications that focus on improving the management of this condition as well as those that seek to optimize translational research efforts. RECENT FINDINGS A number of clinical decision rules are available to assist in the identification of low-risk fever and neutropenia however few have undergone external validation and formal impact analysis. Emerging evidence suggests acute fever and neutropenia management strategies should include time to antibiotic recommendations, and quality improvement initiatives have focused on eliminating barriers to early antibiotic administration. Despite reported increases in antimicrobial resistance, few studies have focused on the prediction, prevention, and optimal treatment of these infections and the effect on risk stratification remains unknown. A consensus guideline for paediatric fever and neutropenia research is now available and may help reduce some of the heterogeneity between studies that have previously limited the translation of evidence into clinical practice. SUMMARY Risk stratification is recommended for children with cancer and fever and neutropenia. Further research is required to quantify the overall impact of this approach and to refine exactly which children will benefit from early antibiotic administration as well as modifications to empiric regimens to cover antibiotic-resistant organisms.
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Ammann RA, Laws HJ, Schrey D, Ehlert K, Moser O, Dilloo D, Bode U, Wawer A, Schrauder A, Cario G, Laengler A, Graf N, Furtwängler R, Simon A. Bloodstream infection in paediatric cancer centres--leukaemia and relapsed malignancies are independent risk factors. Eur J Pediatr 2015; 174:675-86. [PMID: 25804192 DOI: 10.1007/s00431-015-2525-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 03/12/2015] [Accepted: 03/13/2015] [Indexed: 01/05/2023]
Abstract
UNLABELLED In a prospective multicentre study of bloodstream infection (BSI) from November 01, 2007 to July 31, 2010, seven paediatric cancer centres (PCC) from Germany and one from Switzerland included 770 paediatric cancer patients (58% males; median age 8.3 years, interquartile range (IQR) 3.8-14.8 years) comprising 153,193 individual days of surveillance (in- and outpatient days during intensive treatment). Broviac catheters were used in 63% of all patients and Ports in 20%. One hundred forty-two patients (18%; 95% CI 16 to 21%) experienced at least one BSI (179 BSIs in total; bacteraemia 70%, bacterial sepsis 27%, candidaemia 2%). In 57%, the BSI occurred in inpatients, in 79% after conventional chemotherapy. Only 56 % of the patients showed neutropenia at BSI onset. Eventually, patients with acute lymphoblastic leukaemia (ALL) or acute myeloblastic leukaemia (AML), relapsed malignancy and patients with a Broviac faced an increased risk of BSI in the multivariate analysis. Relapsed malignancy (16%) was an independent risk factor for all BSI and for Gram-positive BSI. CONCLUSION This study confirms relapsed malignancy as an independent risk factor for BSIs in paediatric cancer patients. On a unit level, data on BSIs in this high-risk population derived from prospective surveillance are not only mandatory to decide on empiric antimicrobial treatment but also beneficial in planning and evaluating preventive bundles. WHAT IS KNOWN • Paediatric cancer patients face an increased risk of nosocomial bloodstream infections (BSIs). • In most cases, these BSIs are associated with the use of a long-term central venous catheter (Broviac, Port), severe and prolonged immunosuppression (e.g. neutropenia) and other chemotherapy-induced alterations of host defence mechanisms (e.g. mucositis). What is New: • This study is the first multicentre study confirming relapsed malignancy as an independent risk factor for BSIs in paediatric cancer patients. • It describes the epidemiology of nosocomial BSI in paediatric cancer patients mainly outside the stem cell transplantation setting during conventional intensive therapy and argues for prospective surveillance programmes to target and evaluate preventive bundle interventions.
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Affiliation(s)
- R A Ammann
- Department of Paediatrics, University of Bern, Bern, Switzerland,
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Salstrom JL, Coughlin RL, Pool K, Bojan M, Mediavilla C, Schwent W, Rannie M, Law D, Finnerty M, Hilden J. Pediatric patients who receive antibiotics for fever and neutropenia in less than 60 min have decreased intensive care needs. Pediatr Blood Cancer 2015; 62:807-15. [PMID: 25663663 PMCID: PMC4413050 DOI: 10.1002/pbc.25435] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/27/2014] [Accepted: 12/29/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND Antibiotic delivery to patients with fever and neutropenia (F&N) in <60 min is an increasingly important quality measure for oncology centers, but several published reports indicate that a time to antibiotic delivery (TTA) of <60 min is quite difficult to achieve. Here we report a quality improvement (QI) effort that sought to decrease TTA and assess associated clinical outcomes in pediatric patients with cancer and F&N. PROCEDURE We used Lean-Methodology and a Plan-Do-Study-Act approach to direct QI efforts and prospectively tracked TTA measures and associated clinical outcomes (length of stay, duration of fever, use of imaging studies to search for occult infection, bacteremia, intensive care unit (ICU) consultation or admission, and mortality). We then performed statistical analysis to determine the impact of our QI interventions on total TTA, sub-process times, and clinical outcomes. RESULTS Our QI interventions significantly improved TTA such that we are now able to deliver antibiotics in <60 min nearly 100% of the time. All TTA sub-process times also improved. Moreover, achieving TTA <60 min significantly reduced the need for ICU consultation or admission (P = 0.003) in this population. CONCLUSION Here we describe our QI effort along with a detailed assessment of several associated clinical outcomes. These data indicate that decreasing TTA to <60 min is achievable and associated with improved outcomes in pediatric patients with cancer and F&N.
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Affiliation(s)
- Jennifer L Salstrom
- Center for Cancer and Blood Disorders, Children's Hospital ColoradoAurora, Colorado,Department of Pediatrics, University of Colorado Denver Anschutz Medical CampusAurora, Colorado,Department of Biochemistry and Molecular Genetics, University of Colorado Denver Anschutz Medical CampusAurora, Colorado,*Correspondence to: Jennifer L. Salstrom, Department of Biochemistry and Molecular Genetics, University of Colorado Anschutz Medical Campus, 12801 E 17th Ave, MS 8101, L18–9401A, Aurora, CO 80045., E-mail:
| | - Rebecca L Coughlin
- Center for Cancer and Blood Disorders, Children's Hospital ColoradoAurora, Colorado,Process Improvement, Children's Hospital ColoradoAurora, Colorado
| | - Kathleen Pool
- Center for Cancer and Blood Disorders, Children's Hospital ColoradoAurora, Colorado
| | - Melissa Bojan
- Center for Cancer and Blood Disorders, Children's Hospital ColoradoAurora, Colorado
| | - Camille Mediavilla
- Center for Cancer and Blood Disorders, Children's Hospital ColoradoAurora, Colorado
| | - William Schwent
- Process Improvement, Children's Hospital ColoradoAurora, Colorado
| | - Michael Rannie
- Clinical Informatics, Children's Hospital ColoradoAurora, Colorado
| | - Dawn Law
- Clinical Informatics, Children's Hospital ColoradoAurora, Colorado
| | - Michelle Finnerty
- Clinical Application Services, Children's Hospital ColoradoAurora, Colorado
| | - Joanne Hilden
- Center for Cancer and Blood Disorders, Children's Hospital ColoradoAurora, Colorado,Department of Pediatrics, University of Colorado Denver Anschutz Medical CampusAurora, Colorado
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Haeusler GM, Phillips RS, Lehrnbecher T, Thursky KA, Sung L, Ammann RA. Core outcomes and definitions for pediatric fever and neutropenia research: a consensus statement from an international panel. Pediatr Blood Cancer 2015; 62:483-9. [PMID: 25446628 DOI: 10.1002/pbc.25335] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 10/03/2014] [Indexed: 11/05/2022]
Abstract
BACKGROUND There are no specific recommendations for the design and reporting of studies of children with fever and neutropenia (FN). As a result, there is marked heterogeneity in the variables and outcomes that are reported and new definitions continue to emerge. These inconsistencies hinder the ability of researchers and clinicians to compare, contrast and combine results. The objective was to achieve expert consensus on a core set of variables and outcomes that should be measured and reported, as a minimum, in pediatric FN studies. PROCEDURE The Delphi method was used to achieve consensus among an international group of clinicians, pharmacists, researchers, and patient representatives. Four surveys focusing on (i) the identification of a core set of variables and outcomes; and (ii) definitions of these variables and outcomes, were administered electronically. Consensus was predefined as more than 80% agreement on any statement. RESULTS There were forty-five survey participants and the response rate ranged between 84 and 96%. There was consensus on eight core variables and 10 core outcomes that should be collected and reported in all studies of children with FN. Consensus definitions were identified for all of the core outcomes. CONCLUSION Using the Delphi method, expert consensus on a set of core variables and outcomes, and their corresponding definitions, was achieved. These core sets represent the minimum that should be collected and reported in all studies of children with FN. This will promote collaboration and ensure consistency and comparability between studies.
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious Diseases and Infection Control, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Infectious Diseases, Monash Children's Hospital, Monash Health, Melbourne, Australia; Paediatric Integrated Cancer Service, Victoria, Australia
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The influence of different fever definitions on the rate of fever in neutropenia diagnosed in children with cancer. PLoS One 2015; 10:e0117528. [PMID: 25671574 PMCID: PMC4324993 DOI: 10.1371/journal.pone.0117528] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/26/2014] [Indexed: 12/03/2022] Open
Abstract
Background The temperature limit defining fever (TLDF) is based on scarce evidence. This study aimed to determine the rate of fever in neutropenia (FN) episodes additionally diagnosed by lower versus standard TLDF. Methods In a single center using a high TLDF (39.0°C tympanic temperature, LimitStandard), pediatric patients treated with chemotherapy for cancer were observed prospectively. Results of all temperature measurements and CBCs were recorded. The application of lower TLDFs (LimitLow; range, 37.5°C to 38.9°C) versus LimitStandard was simulated in silicon, resulting in three types of FN: simultaneous FN, diagnosed at both limits within 1 hour; earlier FN, diagnosed >1hour earlier at LimitLow; and additional FN, not diagnosed at LimitStandard. Results In 39 patients, 8896 temperature measurements and 1873 CBCs were recorded during 289 months of chemotherapy. Virtually applying LimitStandard resulted in 34 FN diagnoses. The predefined relevantly (≥15%) increased FN rate was reached at LimitLow 38.4°C, with total 44 FN, 23 simultaneous, 11 earlier, and 10 additional (Poisson rate ratioAdditional/Standard, 0.29; 95% lower confidence bound, 0.16). Virtually applying 37.5°C as LimitLow led to earlier FN diagnosis (median, 4.5 hours; 95% CI, 1.0 to 20.8), and to 53 additional FN diagnosed. In 51 (96%) of them, spontaneous defervescence without specific therapy was observed in reality. Conclusion Lower TLDFs led to many additional FN diagnoses, implying overtreatment because spontaneous defervescence was observed in the vast majority. Lower TLDFs led as well to relevantly earlier diagnosis in a minority of FN episodes. The question if the high TLDF is not only efficacious but as well safe remains open.
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Mueller EL, Walkovich KJ, Yanik GA, Clark SJ. Variation in Management of Fever and Neutropenia Among Pediatric Patients With Cancer: A Survey of Providers in Michigan. Pediatr Hematol Oncol 2015; 32:331-40. [PMID: 26086779 PMCID: PMC4807353 DOI: 10.3109/08880018.2015.1036331] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Considerable variation in the management of fever and neutropenia (FN) exists, with factors associated with treatment variation not well described. An online survey of 90 pediatric cancer providers in Michigan was performed in Spring 2014. The survey frame was pediatric patients with cancer receiving treatment, with a Port-a-cath, who were clinically stable. Criteria for "Decreased" and "Increased" risk groups were defined by respondents. Survey questions addressed FN definitions, risk groups conceptualization, routine clinical practice, and management guidelines, in the context of risk groups and distance to treating institution. Fifty providers responded (56%); the majority defined a febrile event as temperature >38.3°C and/or 2 events >38.0°C within a 24-hour period. Neutropenia was defined as current or anticipated absolute neutrophil count (ANC) <500/μL. Majority of respondents recommended "Decreased" and "Increased" patients present to a local emergency department (ED) if they live >2 hours away. Respondents were significantly more likely to have a "Decreased Risk" patient travel over 2 hours if they rated the local ED as "Poor to Fair" on ability to access Port-a-caths (P = .048). Most respondents would discharge patients who are afebrile for 24 hours, blood cultures negative for 48 hours, and neutrophil count of greater than 200/μL; 40% preferred discharge on oral antibiotics when the ANC <500/μL. Triaging for febrile pediatric patients with cancer is significantly influenced by the providers' perceptions of local EDs. Future investigation of local hospitals' ability to provide urgent evaluation, combined with parental perspectives, could lead to improvements in timely and effective management.
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Affiliation(s)
- Emily L. Mueller
- Section of Pediatric Hematology Oncology, Department of Pediatrics, Indiana University, Indianapolis, IN 46202,Pediatric and Adolescent Comparative Effectiveness Research, Indiana University, Indianapolis, IN 46202
| | - Kelly J. Walkovich
- Division of Pediatric Hematology Oncology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, 48109
| | - Gregory A. Yanik
- Division of Pediatric Hematology Oncology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, 48109
| | - Sarah J. Clark
- Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, 48109
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Furtwängler R, Hauschild AC, Hübel J, Rakicioglou H, Bödeker B, Maddula S, Simon A, Baumbach JI. Signals of neutropenia in human breath? ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s12127-014-0145-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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21
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Binz P, Bodmer N, Leibundgut K, Teuffel O, Niggli FK, Ammann RA. Different fever definitions and the rate of fever and neutropenia diagnosed in children with cancer: a retrospective two-center cohort study. Pediatr Blood Cancer 2013. [PMID: 23193083 DOI: 10.1002/pbc.24380] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The definition of fever, and thus fever and neutropenia (FN), varies between different pediatric oncology centers. Higher temperature limit should reduce FN rates, but may increase rates of FN with complications by delaying therapy. This study determined if different fever definitions are associated with different FN rates. PROCEDURE Two pediatric oncology centers had used three fever definitions in 2004-2011: ear temperature ≥38.5 °C persisting ≥2 hours (low definition); axillary temperature ≥38.5 °C ≥ 2 hours or ≥39.0 °C once (middle); and ear temperature ≥39.0 °C once (high). Clinical information was retrospectively extracted from charts. FN rates were compared using mixed Poisson regression. RESULTS In 521 pediatric patients with cancer, 783 FN were recorded during 6,009 months cumulative chemotherapy exposure time (501 years; rate, 0.13/month [95% CI, 0.12-0.14]), 124 of them with bacteremia (16%; 0.021/month [0.017-0.025]). In univariate analysis, the high versus low fever definition was associated with a lower FN rate (0.10/month [0.08-0.11] vs. 0.15/month [0.13-0.16]; rate ratio, 0.66 [0.45-0.97]; P = 0.036), the middle definition was intermediate (0.13/month [0.11-0.15]). This difference was not confirmed in multivariate analysis (rate ratio, 0.94 [0.67-1.33]; P = 0.74). The high versus low definition was not associated with an increased rate of FN with bacteremia (multivariate rate ratio, 1.39 [0.53-3.62]; P = 0.50). CONCLUSION A higher fever definition was not associated with a lower FN rate, nor with an increased rate of FN with bacteremia. These may be false negative findings due to methodological limitations. These questions, with their potential impact on health-related quality of life, and on costs, need to be assessed in prospective studies.
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Affiliation(s)
- Patrizia Binz
- Department of Pediatrics, University of Bern, Bern, Switzerland
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